Arteria trigeminal persistente y VI par craneal aislado / Persistent trigeminal artery and isolated sixth cranial nerve

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[Arterial gas embolism progressing to a massive stroke]. / Embolismo gaseoso arterial con evolución a accidente cerebrovascular masivo.

INTRODUCTION: Arterial gas embolism (AGE) is a main iatrogenic complication resulting from the use of invasive procedures. It is difficult to diagnose if it is not clinically suspected. CASE REPORT: A 67-year-old male patient, with a history of interventions involving a mitral prosthesis and a double aortocoronary bypass, who visited Emergency room with symptoms of a high temperature and general malaise. He was canalised peripherally and the electrocardiogram (ECG) showed an auricular fibrillation that had already been detected. While under observation he suffered a loss of consciousness, generalised hypotonia, conjugated gaze deviation towards the right, lower left facial paralysis and left Babinski positive. A new ECG showed ST segment elevation in V2-V5. A cranial computerised tomography (CAT) scan with no contrast revealed a number of serpiginous images caused by the presence of air in vascular structures. A second cranial CAT scan showed the disappearance of the visible air and signs of ischemic stroke in the territory of the right middle and posterior cerebral arteries and the left middle cerebral artery. Clinical-radiological findings suggested an AGE in the brain with massive stroke and acute myocardial infarct with similar causation. CONCLUSIONS: It is not clear what caused the air embolism in this patient but it can most probably be explained by air accidentally entering a peripheral vein. Carrying out an early cranial CAT scan can provide us with a diagnosis and a later CAT scan can evaluate the consequences of the embolism.

Embolismo gaseoso arterial con evolución a accidente cerebrovascular masivo / Arterial gas embolism progressing to a massive stroke

Introducción. El embolismo gaseoso arterial (EGA) es una complicación principalmente yatrogénica, causada por el uso de procedimientos invasivos. Su diagnóstico es difícil si no se sospecha clínicamente. Caso clínico. Varón de 67 años, con antecedente de intervención de prótesis mitral y doble derivación aortocoronaria, que acude a Urgencias con un síndrome febril y mal estado general. Se le canaliza una vía periférica, y en el electrocardiograma (ECG) muestra una fibrilación auricular ya conocida. Mientras estaba en observación, sufre pérdida de conciencia, hipotonía generalizada, desviación de la mirada conjugada a la derecha, parálisis facial inferior izquierda y Babinski izquierdo positivo. Un nuevo ECG muestra supradesnivel del segmento ST de V2 a V5. En la tomografía computarizada (TC) craneal sin contraste se observan múltiples imágenes serpiginosas por aire en estructuras vasculares. Una segunda TC craneal muestra la desaparición del aire visible y signos de accidente cerebrovascular isquémico en el territorio de las arterias cerebral media y posterior derechas y cerebral media izquierda. Los hallazgos clinicorradiológicos sugieren un EGA cerebral con infarto cerebral masivo, e infarto agudo de miocardio de origen similar. Conclusiones. La causa del embolismo aéreo en este paciente no está clara, y la más probable es la entrada accidental de aire en la vía venosa periférica. La realización de una TC craneal precoz puede dar el diagnóstico, y una TC tardía puede valorar las consecuencias del embolismo (AU)

Introduction. Arterial gas embolism (AGE) is a main iatrogenic complication resulting from the use of invasive procedures. It is difficult to diagnose if it is not clinically suspected. Case report. A 67-year-old male patient, with a history of interventions involving a mitral prosthesis and a double aortocoronary bypass, who visited Emergency room with symptoms of a high temperature and general malaise. He was canalised peripherally and the electrocardiogram (ECG) showed an auricular fibrillation that had already been detected. While under observation he suffered a loss of consciousness, generalised hypotonia, conjugated gaze deviation towards the right, lower left facial paralysis and left Babinski positive. A new ECG showed ST segment elevation in V2-V5. A cranial computerised tomography (CAT) scan with no contrast revealed a number of serpiginous images caused by the presence of air in vascular structures. A second cranial CAT scan showed the disappearance of the visible air and signs of ischemic stroke in the territory of the right middle and posterior cerebral arteries and the left middle cerebral artery. Clinical-radiological findings suggested an AGE in the brain with massive stroke and acute myocardial infarct with similar causation. Conclusions. It is not clear what caused the air embolism in this patient but it can most probably be explained by air accidentally entering a peripheral vein. Carrying out an early cranial CAT scan can provide us with a diagnosis and a later CAT scan can evaluate the consequences of the embolism (AU)

Neumocéfalo tras anestesia epidural / Pneumocephalus following epidural anaesthesia

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Colocación de endoprótesis vascular sin dilatación previa en estenosis intracraneal de la carótida interna. A propósito de un caso / Stenting without prior dilatation in intracranial stenosis of the internal carotid artery: a case report

Introducción. Se ha publicado recientemente la aplicación de stents coronarios para el tratamiento de las estenosis de la arteria carótida interna (ACI) intracraneal, sobre todo en pacientes sin respuesta a tratamiento médico y con progresión de los síntomas neurológicos. El stenting en las lesiones vasculares intracraneales del territorio carotídeo se ha usado casi exclusivamente para el tratamiento de las complicaciones debidas a la angioplastia transluminal con balón. En casos seleccionados y sin dilata ción previa de la estenosis podríamos colocar un stent. Caso clínico. Presentamos un caso de stenting carotídeo intracraneal, sin dilatación previa, en un paciente varón de 57 años con múltiples factores de riesgo arterioscleróticos. El paciente presentaba síntomas neurológicos sin respuesta a tratamiento médico, debidos a una estenosis mayor del 70% del segmento cavernoso de la ACI derecha, demostrada en el estudio arteriográfico. La anatomía favorable y el material utilizado permitieron el paso del stent por la estenosis sin necesidad de dilatación. No se observaron complicaciones inmediatas, y se visualizó una arteria carótida de calibre normal de la estenosis y se mostraba un angiograma cerebral normal. El paciente continúa con tratamiento médico y permanece neurológicamente estable en el seguimiento clínico durante 9 meses. Conclusión. En casos seleccionados, la colocación de un stent carotídeo intracraneal, sin dilatación previa con balón, puede ofrecer un buen resultado para evitar las complicaciones de la angioplastia (disección, rotura o embolismo) (AU)

Introduction. Recent reports have described the application of coronary stents for the treatment of intracranial stenosis of the internal carotid artery (ICA), above all in patients who do not respond to medical treatment and display advancing neurological symptoms. Stenting in intracranial vascular lesions of the carotid territory has been used almost exclusively in the treatment of the complications due to transluminal angioplasties with balloons. In selected cases and without prior dilatation of the stenosis it would be possible to place a stent. Case report. We describe a case of intracranial carotid stenting, without previous dilatation, in a 57- year-old male patient with multiple arteriosclerotic risk factors. The patient presented neurological symptoms with no response to medical treatment, caused by a stenosis that affected over 70% of the cavernous segment of the right ICA, which was shown up by the arteriographic study. A favourable anatomy and the material used allowed the stent to pass through the stenosis without the need for dilatation. No immediate complications were observed and the carotid artery was seen to be of a normal calibre for stenosis. The brain angiogram also proved to be normal. The patient continues with the medical treatment and has remained neurologically stable throughout the 9-month clinical follow-up. Conclusion. In certain selected cases, placing an intracranial carotid stent, without previous balloon dilatation, can give good results and prevent the complications that can accompany angioplasty (such as dissection, rupture or embolism) (AU)

[The relation between the clinical symptoms and the findings on magnetic resonance in children with periventricular leukomalacia]. / Relación entre los síntomas clínicos y los hallazgos en resonancia magnética en niños con leucomalacia periventricular.

OBJECTIVES: To assess whether there is a relationship between the various clinical symptoms and imaging findings on MR in children with periventricular leukomalacia (PVLM). PATIENTS AND METHODS: We made a retrospective study of 41 consecutive paediatric patients, 19 boys and 22 girls, with an average age of 30.5+/-19 months (range 8 84 months) who had been diagnosed as having PVLM and studied using MR, recording imaging, clinical and epidemiological data. RESULTS: The MR images showed areas of gliosis in all the children (few foci in 68.3% and multiple foci in 31.7%), with cysts in 22%. The changes were seen mainly in the parietal and occipital regions, were bilateral and symmetrical in 80.5%, with ventricular dilatation in 75.6%, atrophy of the parenchyma in 48.8%, Wallerian degeneration in 7.3%, delay in myelination in 31.7%, lesions in the optic radiations in 9.8%, thalamus 12.2% and anomalous venous drainage in 2.4%. The overall degree of involvement on MR was severe in 43.9%, moderate in 31,7% and mild in 24.4%. There was a history of perinatal foetal distress in 56.8%, hyaline membrane disease in 40.5%, intracranial hemorrhage in 35.1%, psychomotor retardation in 58.5%, motor retardation in 29.3%, and squint in 22%. A significant relationship was found only between acute foetal distress and lateralization of the lesions (p= 0.038) and the presence of parenchymatous cysts (p= 0.024). CONCLUSION: The patients with a history of foetal distress had a greater tendency to symmetrical, bilateral involvement with cysts in the white matter of the brain. It was not possible to establish a model for classification of the overall involvement using MR and the data recorded. The imaging findings were not related overall to the patients symptoms.

Relación entre los síntomas clínicos y los hallazgos en resonancia magnética en niños con leucomalacia periventricular / The relation between the clinical symptoms and the findings on magnetic resonance in children with periventricular leukomalacia

Objetivos. Valorar si existe una relación entre los diversos síntomas clínicos y los hallazgos de imagen observados mediante resonancia magnética (RM) en niños con leucomalacia periventricular (LMPV). Pacientes y métodos. Estudio retrospectivo de 41 pacientes pediátricos consecutivos, 19 de sexo masculino y 22 femenino, con una edad media de 30,5ñ19 meses (intervalo, 8-84 meses), diagnosticados de LMPV y examinados con RM, y en el que se han recogido diversas variables de imagen, clínicas y epidemiológicas. Resultados. En las imágenes de RM se observaron áreas de gliosis en todos los niños (focos escasos en 68,3 por ciento y múltiples en 31,7 por ciento) con quistes en el 22 por ciento. La localización de estas alteraciones fue predominantemente parietal y occipital, bilateral y simétrica (80,5 por ciento), con dilatación ventricular (75,6 por ciento), atrofia parenquimatosa (48,8 por ciento), degeneración walleriana (7,3 por ciento), retraso en la mielinización (31,7 por ciento), lesiones en las radiaciones ópticas (9,8 por ciento) y tálamos (12,2 por ciento), y venas de drenaje anómalas (2,4 por ciento). El grado de afectación global en RM fue grave (43,9 por ciento), moderado (31,7 por ciento) y leve (24,4 por ciento). Hubo antecedentes de sufrimiento fetal perinatal (56,8 por ciento), enfermedad de la membrana hialina (40,5 por ciento) y hemorragia intracraneal (35,1 por ciento), presentándose con retraso psicomotor (58,5 por ciento) o motor (29,3 por ciento) y estrabismo (22 por ciento). Sólo se detectaron relaciones significativas entre el sufrimiento fetal agudo y la lateralización de las lesiones (p= 0,038) y presencia de quistes parenquimatosos (p= 0,024). Conclusiones. Los pacientes con sufrimiento fetal presentan una mayor tendencia a la afectación bilateral y simétrica, y a presentar quistes en la sustancia blanca. No se ha podido establecer un modelo de clasificación de la afectación global mediante RM y las variables clínicas recogidas. Los hallazgos de imagen no se relacionan globalmente con la sintomatología del paciente (AU)

Klippel-Trenaunay syndrome: frequency of cerebral and cerebellar hemihypertrophy on MRI.

We examined 11 patients, clinically and radiographically diagnosed as having the Klippel-Trenaunay syndrome (KTS) by MRI. There were four females and seven males, aged 3-51 years (mean 21 years). Two had clear asymmetry of the cerebral and cerebellar hemispheres. The thickness of the grey matter was normal, without sulcation abnormalities, but the thickness of the white matter was increased; the size of the ipsilateral ventricle was normal. These patients had hypertrophy of the leg and a cutaneous haemangioma on the same side as the brain abnormality. No patient had an intracranial vascular malformation, unilateral megalencephaly, cerebral atrophy or hydrocephalus. The prevalence of cerebral hemihypertrophy in our series of patients with KTS was thus 18%.

MnDPDP enhancement characteristics and differentiation between cirrhotic and noncirrhotic livers.

RATIONALE AND OBJECTIVES: The objective was to analyze if liver enhancement with mangafodipir trisodium was influenced by liver cirrhosis. METHODS: Eighty patients (49 with cirrhotic and 31 with noncirrhotic livers) were studied with spin-echo and spoiled gradient-echo T1-weighted images, before and after administration of mangafodipir trisodium. Hepatic insufficiency was assessed using the Child classification. Image analysis was performed both qualitatively and quantitatively. RESULTS: Noncirrhotic livers enhanced homogeneously but 37% of cirrhotic livers did not; the difference was significant. Areas corresponding to collapsed fibrous zones enhanced less than the rest of the parenchyma; areas of regenerating nodular zones enhanced more. Signal-to-noise ratios were significantly less for cirrhotic livers on postcontrast spoiled gradient-echo images. Cirrhotic livers had significantly lower relative enhancement ratios than noncirrhotic ones. The Child index and aspartate aminotransferase values were statistically related to the enhancement ratio. CONCLUSIONS: Mangafodipir trisodium enhancement in cirrhotic livers is related to necrosis and regeneration of the hepatocytes. Cirrhotic livers enhanced less than noncirrhotic ones.

Neurofibromatosis type 1 in children: MR imaging and follow-up studies of central nervous system findings.

PURPOSE: To determine the frequency, evolution and diagnostic impact of characteristic central nervous system MR imaging lesions in children with neurofibromatosis type 1 (NF1). SUBJECTS: We reviewed 89 children with established or clinically suspected disease. A final diagnosis of NF1 was made in 72 (age range, 10 months to 14 years). RESULTS: Hyperintense lesions on long TR images were detected in 78% of patients, principally involving the basal ganglia, cerebellum and brain stem. In 30% of the globus pallidus lesions, hyperintensity was seen on short TR images, being usually isointense on IR T1 weighted images. Globus pallidus lesions did not enhance. Eight patients presented atypical unenhanced lesions showing either edema, mass effect or hypointensity on short TR images; 2 of them were considered symptomatic brain stem gliomas. Six other children showed one or more growing enhanced cerebral lesions classified as tumors. Other child developed a growing enhanced lesion that markedly decreased in the follow-up studies. Twenty patients (28%) had optic gliomas. In two children, under 6 years old, this tumor appeared de novo. Forty-five children had several follow-up MR imaging studies (mean interval, 3 years). Regression of the basal ganglia lesions, both in size and/or intensity was noticed in 42% of cases, enlargement or new appearance of lesions in 24.5%, mixed increased/decreased in 7%, and stability in 26.5%. White matter lesions of the cerebellum and brain stem decreased in size in 40%, grew in 15.5%, showed a mixed increased/decreased pattern in 11%, and remained unchanged in 33.5% of cases. An involutional tendency of these lesions occurred in children older than 10 years, while progression was more frequent in younger children (P<0.05). CONCLUSIONS: Hyperintense lesions are highly prevalent and characteristic in patients with NF1. MR imaging contributed to a definitive diagnosis of NF1 in 53% of suspected cases. Follow-up studies are necessary in the evaluation of suspected NF1, even if the first examination is negative.

[Intra-arterial fibrinolysis in acute thrombosis of the basilar artery]. / Fibrinólisis intrarterial en la trombosis aguda de la arteria basilar.

INTRODUCTION: Ischemia in the territory of the basilar artery presents with a variable clinical picture of hemiparesia-tetraplegia, progressive deterioration of level of consciousness, irregular respiration and apnea leading to irreversible coma and death in between 75% and 86% of cases. The usual treatment is supportive. CLINICAL CASE: We present the case of a 49 year old woman with acute thrombosis of the basilar artery and a progressive course leading to coma. No bulbar lesions were seen on the CT scan done in the Emergency Department. Thrombosis of the basilar artery and permeable bilateral carotid systems were shown on arteriography. There were no contra-indications to fibrinolysis. Following local fibrinolytic treatment with urokinase the patient had full recovery from her neurological disorder and no sequelae. The basilar artery remained permeable six months later. CONCLUSIONS: Emergency treatment with cerebral intra-arterial fibrinolysis within the first six hours, in a case of neurological deficit progressing in the basilar artery territory, with persistence of brain-stem functions and no signs of decerebration (provided there are no contra-indications to fibrinolysis and the initial cerebral CT scan shows no bulbar lesions) may save the patient's life, with total or partial recovery of brain-stem function.

Tumoural portal vein thrombosis. Enhancement with MnDPDP.

PURPOSE: Intrahepatic thrombus is usually associated with either cirrhosis or hepatocellular carcinoma (HCC). Most HCCs enhance after the administration of MnDPDP (Teslascan). Our objective was to analyze the enhancement characteristics of tumour portal vein thrombi. MATERIAL AND METHODS: Thrombi affecting the main or segmental portal veins (17 cases) and the suprahepatic inferior vena cava (1 case) were retrospectively selected from a series of 128 patients studied with MR imaging before and after the administration of MnDPDP. Enhancement was assessed qualitatively and quantitatively. RESULTS: All tumour thrombi enhanced after MnDPDP administration. The enhancement was more conspicuous in the GRE images. On the quantitative evaluation, the portal thrombus enhancement was greater for GRE images than SE images. Portal thrombi enhanced more than the liver and the HCCs. There was a significant difference between the enhancement of the HCCs and the thrombi with both MR imaging techniques. CONCLUSION: The greater enhancement of the tumour thrombus associated with the liver and HCC may suggest that other mechanisms, apart from accumulation of the contrast medium within the hepatocytes inside the thrombi, are involved in thrombus enhancement.

Randomised double-blind clinical trial of intermediate- versus high-dose chloral hydrate for neuroimaging of children.

Orally administered chloral hydrate is the most widely used sedative in children undergoing MRI. We compared intermediate- and high-dose oral chloral hydrate in 97 consecutive children undergoing MRI in a prospective, controlled, double-blind, randomised clinical trial. There were 50 girls and 47 boys, mean weight (+/- SD) 14.7 +/- 6.4 kg, and mean age 38 +/- 31. The children were randomly allocated to receive chloral hydrate syrup either 70 mg/kg (group A, n = 50) or 100 mg/kg (group B, n = 47). These two groups were not significantly different in sex, weight, age, diagnosis or ambulatory medication. The mean initial dose (+/- SEM) was 64 +/- 2 mg/kg for group A and 93 +/- 2 mg/kg for group B. Because adequate sedation was not achieved, 14 patients in group A and 6 in group B required a second dose, giving a mean total dose of 70 +/- 2 mg/kg for group A and 96 +/- 2 mg/kg for group B. The percentage of successful examinations after the initial dose (A: 64%, B: 87%; p < 0.05) and the total dose (A: 92%, B:100%; p = 0.14) was higher in group B. Significant differences were found for the time of onset of sedation (A:28 +/- 2 min, B: 21 +/- 1 min; p < 0.05), but not for the time to spontaneous awakening after the completion of the examination. The rate of adverse reactions was similar (A: 20%, B: 21%; p = 1.00). We conclude that high-dose oral chloral hydrate improves the management of children undergoing MRI.

[MELAS syndrome: clinical, pathological and neuroimaging study]. / Síndrome de Melas: estudio clínico, patológico y de neuroimagen.

The form of presentation of a new case of Melas Syndrome is described, together with a pathological and neuroimage study, including clinical development over a 3 year period. The usefulness of MR should be underlined here, given clinical doubts, and also normality in the EMG early phases of and the association with obstructive hypertrophic miocardiopathy.

Oral chloral hydrate provides effective and safe sedation in paediatric magnetic resonance imaging.

Sedation is routinely required for successful Magnetic Resonance imaging in infants and children. Five hundred and ninety-six paediatric patients (270 female and 326 male, age (mean +/- SD) 41 +/- 30 months and weight 14.8 +/- 6.5 kg) entered an open, non-comparative, prospective study to assess oral chloral hydrate sedation in a large and homogeneous paediatric population undergoing Magnetic Resonance imaging. Chloral hydrate syrup 70 mg/ml was administered 20-40 min prior to the procedure. Effective sedation was reached in 94.1% with a total dose (mean +/- SEM) of 68 +/- 1 mg/kg (range 20-170 mg/kg). Statistical analysis of sedation failures vs. successful examinations after the total dose showed significant differences for dose (62 +/- 4 vs. 69 +/- 1 mg/kg; P < 0.05), age (64 +/- 7 vs. 40 +/- 1 months; P < 0.001) and weight (19.8 +/- 1.5 vs. 14.5 +/- 0.0 kg; P < 0.001). Effectiveness fell to around 80% in children with encephalic white matter alterations, medullary tumours or syringohydromyela (P = 0.07). The mean time of onset of sedation was 26 +/- 1 min, and the mean time to spontaneous awakening after the completion of the Magnetic Resonance examination was 38 +/- 2 min. Fifty-nine children (9.9%) experienced adverse reactions, with nausea and vomiting being the most common (n = 41), followed by nervousness and unusual excitement (n = 6). Discriminant function analysis identified age and total dose as the quantitative variables helping to differentiate between sedation failures and satisfactory examinations (sensitivity = 0.73, and specificity = 0.61; r = 0.20, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prenatal diagnosis of idiopathic neonatal hemochromatosis with MRI.

Intrauterine diagnosis of perinatal hemochromatosis is difficult. Noninvasive detection of hepatic iron deposition is crucial. We report the first case diagnosed intrauterine with magnetic resonance imaging (MRI). By visual analysis, if the fetal liver is less intense than maternal or fetal fat signal for T2* gradient echo image, hemochromatosis should be suggested.