Treatment of traumatic cervical arteriovenous fistulas with N-butyl-2-cyanoacrylate.

We report 2 cases of traumatic arteriovenous fistulas in the neck treated with transarterial embolization with n-butyl-2-cyanoacrylate (n-BCA). In both cases, covered stent placement across the fistula to preserve the artery was not possible. Detachable coil placement was attempted in one case but was not successful. Both fistulas were successfully treated with n-BCA embolization. To our knowledge, these are the first 2 such cases reported of high-flow cervical arteriovenous fistulas treated with n-BCA embolization.

Endovascular embolization of the swine rete mirabile with Eudragit-E 100 polymer.

BACKGROUND AND PURPOSE: Both adhesive and nonabrasive embolic agents are available for arteriovenous malformation (AVM) embolization. The purpose of this study was to evaluate a novel ethanol-based nonadhesive liquid embolic material in a swine AVM model. MATERIALS AND METHODS: Eudragit (copolymer of methyl and butyl methacrylate and dimethylaminoethyl methacrylate) was dissolved in 50% ethanol and 50% iopamidol. Eudragit was injected into 9 retia mirabilia (RMs). Ethanol and iopamidol mixture were injected into 4 RMs for comparison. Three RMs embolized with Eudragit mixture were evaluated both angiographically and histopathologically acutely (3-24 hours) and at 30 days and 90 days after embolization. RESULTS: No procedural complications from Eudragrit embolization were noted, including retention or adhesion of the microcatheter. Various degrees of inflammation were observed in the acute and 30-day specimens. Two RMs showed partial recanalization on both histopathology and follow-up angiography in the 30-day group. Arterial fibrosis and calcification were observed in the 30- and 90-day specimens. The internal elastic lamina was disrupted in the 30- and 90-day specimens, but there was no evidence of Eudragit extravasation or hemorrhage. Endothelial damage was seen in all specimens and was particularly severe in the 30- and 90-day specimens. CONCLUSION: Eudragit polymer induced inflammation in thrombosis similar to n-butyl 2-cyanoacrylate, but without the disadvantages of perivascular hemorrhage and extravasation of embolization material. Although recanalization of some embolized RMs was noted, further investigation into Eudragit as a potentially useful embolic material for brain AVMs is warranted.

Patient Outcomes and Cerebral Infarction after Ruptured Anterior Communicating Artery Aneurysm Treatment.

BACKGROUND AND PURPOSE: Anterior communicating artery aneurysm rupture and treatment is associated with high rates of dependency, which are more severe after clipping compared with coiling. To determine whether ischemic injury might account for these differences, we characterized cerebral infarction burden, infarction patterns, and patient outcomes after surgical or endovascular treatment of ruptured anterior communicating artery aneurysms. MATERIALS AND METHODS: We performed a retrospective cohort study of consecutive patients with ruptured anterior communicating artery aneurysms. Patient data and neuroimaging studies were reviewed. A propensity score for outcome measures was calculated to account for the nonrandom assignment to treatment. Primary outcome was the frequency of frontal lobe and striatum ischemic injury. Secondary outcomes were patient mortality and clinical outcome at discharge and at 3 months. RESULTS: Coiled patients were older (median, 55 versus 50 years; P = .03), presented with a worse clinical status (60% with Hunt and Hess Score >2 versus 34% in clipped patients; P = .02), had a higher modified Fisher grade (P = .01), and were more likely to present with intraventricular hemorrhage (78% versus 56%; P = .03). Ischemic frontal lobe infarction (OR, 2.9; 95% CI, 1.1-8.4; P = .03) and recurrent artery of Heubner infarction (OR, 20.9; 95% CI, 3.5-403.7; P < .001) were more common in clipped patients. Clipped patients were more likely to be functionally dependent at discharge (OR, 3.2; P = .05) compared with coiled patients. Mortality and clinical outcome at 3 months were similar between coiled and clipped patients. CONCLUSIONS: Frontal lobe and recurrent artery of Heubner infarctions are more common after surgical clipping of ruptured anterior communicating artery aneurysms, and are associated with poorer clinical outcomes at discharge.

Specific estrogen receptor binding and biological effects of 16 alpha-iodoestradiol on human breast cancer cells.

16 alpha-Iodoestradiol was evaluated as an estrogen in MCF-7 and ZR-75-1 human breast cancer cells. 16 alpha-[125I]Iodoestradiol binds to equivalent numbers of specific estrogen receptors with a comparable binding affinity and similar sucrose density gradient behavior. 16 alpha-Iodoestradiol translocates receptor sites to the nucleus and induces a full range of estrogenic effects including thymidine incorporation, cell growth, and progesterone receptor. Because of its high specific activity, this compound may have unique applications on imaging of estrogen receptor-containing cells and specific receptor-mediated cytotoxicity.

Distribution, frequency, and quantitative analysis of estrogen, progesterone, androgen, and glucocorticoid receptors in human breast cancer.

The distribution and frequency of steroid hormone receptors are described 329 patients with breast cancer. The distribution of each of the steroid hormone receptors is unimodal with a progressive increase in the proportion of patients positive at lower receptor values. Receptor values expressed as fmol/mg cytoplasmic protein are well correlated with values expressed as fmol/mg breast tumor. Estrogen receptor was positive in 53% of the patients; progesterone receptor was positive in 38% of the patients; glucocorticoid receptor was positive in 52% of the patients; and androgen receptor was positive in 31% of the patients. The type of tissue assayed did not affect steroid hormone receptor positivity. For primary tumors, there was no correlation between steroid hormone receptor positivity and location of the tumor in the breast, size of the tumor, or extent of the disease. Each of the steroid hormone receptors was positively associated with each of the other steroid hormone receptors. Estrogen receptor was correlated with menopausal status and axillary nodal status, but these correlations did not exist for the other steroid hormone receptors. Estrogen receptor was not correlated with age after adjustment for menopausal status. The other steroid hormone receptors were not correlated with age.

PIP: This study describes the distribution and frequency of estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), and glucocorticoid receptor (GR) in a large series of patients with primary metastatic breast cancer. 329 patients were in this series. All 4 steroid hormone receptors were present in the population: ER was positive in 53%, PR was positive in 38%, AR was positive for 31%, and GR was positive in 52%. Next, the distribution of ERs as well as the distributions of PR, AR, and GR values seemed unimodal. There was a very high correlation between any steroid hormone receptor value expressed as either fmol/mg of cytoplasmic protein or fmol/mg of breast tumor. Of more importance was that alternate methods of data expression did not alter the classification of values as positive or negative. No correlation was found between any of the steroid hormone receptors and laterality of the breast tumor, location and size of the primary tumor, extent of disease, or type of tissue assayed. None of the steroid hormone receptors correlated with age. There was a strong correlation noted between ER values and menopausal status. Neither PR, AR, nor GR was significantly associated with menopausal status. ER status was correlated with axillary nodal status, with the ER positive group containing a high proportion of node-negative patients. Finally, quantitative analysis of steroid receptor hormone values demonstrated correlations among other receptors. Plotting values of any 1 receptor vs. any other receptor resulted in a positive Kendall rank test correlation which was highly significant.

Relationship between the progesterone, androgen, and glucocorticoid receptor and response rate to endocrine therapy in metastatic breast cancer.

PIP: 85 patients with metastatic or surgically unrecsectable primary breast cancer who had had 1 or more steroid hormone receptor assays performed immediately before the institution of endocrine therapy were studied retrospectively to determine any influence of steroid hormone receptors on response rate to endocrine therapy. Included in addition to effects of estrogen receptor (ER) status are the effects of androgen receptor (AR), progesterone receptor (PR), and glucocorticoid receptor (GR) on therapy perfornamce. Of 18 patients whose tumor contained PR, 11 responded to endocrine therapy, compared with 8 of 26 patients with low or absent PR. PR increased the predictive index of the ER in an group of patients who had received no prior therapy, but it did not help in patients who had received prior endocrine therapy. 0 of 4 patients whose tumors were ER negative but PR positive responded to endocrine therapy. Present trends suggest a possible association between AR and GR and response to endocrine therapy. A cut-off value of 10 fmol/mg of cytoplasmic protein was needed to make these trends apparent. The distributions of AR and GR values for responders and nonresponders were not significantly different. Knowledge of AR status does not increase the protective index in ER-positive or ER-negative tumors. GR positivity may increase the predictive index in ER-positive tumors, but not in ER-negative ones.^ieng

Brown-Séquard syndrome of the cervical spinal cord after chiropractic manipulation.

We report a case of increased signal in the left hemicord at the C4 level on T2-weighted MR images after chiropractic manipulation, consistent with contusion. The patient displayed clinical features of Brown-Séquard syndrome, which stabilized with immobilization and steroids. Follow-up imaging showed decreased cord swelling with persistent increased signal. After physical therapy, the patient regained strength on the left side, with residual decreased sensation to pain involving the right arm.

Imaging of acute subarachnoid hemorrhage with a fluid-attenuated inversion recovery sequence in an animal model: comparison with non-contrast-enhanced CT.

BACKGROUND AND PURPOSE: Fluid-attenuated inversion recovery (FLAIR) MR imaging sequences have been previously described in the evaluation of acute subarachnoid hemorrhage (SAH) in human subjects and have demonstrated good sensitivity. The purpose of this study was to evaluate a FLAIR sequence in an animal model of SAH and to compare the results with those obtained with non-contrast-enhanced CT. METHODS: SAH was experimentally induced in 18 New Zealand rabbits by injecting autologous arterial blood into the subarachnoid space of the foramen magnum. Nine animals had high-volume (1-2 mL) injections, and nine animals had low-volume (0.2-0.5 mL) injections. Four control animals were injected with 0.5 mL of saline. The animals were imaged with a FLAIR sequence and standard CT 2-5 hours after injection. Gross pathologic evaluation of seven of the animals was performed. Four blinded readers independently evaluated the CT and FLAIR images for SAH and graded the probability of SAH on a scale of 1 to 5 (1 = no hemorrhage, 5 = definite hemorrhage). RESULTS: Overall, the sensitivity of FLAIR was 89%, and the sensitivity of CT was 39% (P <.01). In animals with a high volume of SAH, the sensitivity of FLAIR was 100%, and the sensitivity of CT was 56%. In animals with a low volume of SAH, the sensitivity of FLAIR was 78%, and the sensitivity of CT was 22%. The specificity of FLAIR in animals without SAH was 100%, and the specificity of CT was 100%. The average reader score for FLAIR was 3.8, and that for CT was 2.2 (P <.001). Reader scores for FLAIR were higher than those for CT in 94% (P <.01) of animals with SAH and in 25% of animals without SAH (P >.05). Seven animals underwent gross pathologic examination, and all had blood in the subarachnoid space around the brain stem. CONCLUSION: FLAIR was more sensitive than CT in the evaluation of acute SAH in this model, especially when a high volume of SAH was present. This study provides a model for further experimentation with MR imaging in the evaluation of SAH. These findings are consistent with those of current clinical literature, which show FLAIR to be an accurate MR sequence in the diagnosis of SAH.

The fate of neuroradiologic abstracts presented at national meetings in 1993: rate of subsequent publication in peer-reviewed, indexed journals.

BACKGROUND AND PURPOSE: Abstract presentations are a valuable means of rapidly conveying new information; however, abstracts that fail to eventually become published are of little use to the general medical community. Our goals were to determine the publication rate of neuroradiologic papers originally presented at national meetings in 1993 and to assess publication rate as a function of neuroradiologic subspecialty and study design. METHODS: Proceedings from the 1993 ASNR and RSNA meetings were reviewed. A MEDLINE search encompassing 1993-1997 was performed cross-referencing lead author and at least one text word based on the abstract title. All ASNR and RSNA neuroradiologic abstracts were included. Study type, subspecialty classification, and sample size were tabulated. Publication rate, based on study design and neuroradiologic subspecialty, was compared with overall publication rate. Median duration from meeting presentation to publication was calculated, and the journals of publication were noted. RESULTS: Thirty-seven percent of ASNR abstracts and 33% of RSNA neuroradiologic abstracts were published as articles in indexed medical journals. Publication rates among neuroradiologic subspecialty types were not significantly different. Prospective studies presented at the ASNR were published at a higher rate than were retrospective studies. There was no difference between the publication rate of experimental versus clinical studies. Neuroradiologic abstracts were published less frequently than were abstracts within other medical specialties. Median time between abstract presentation and publication was 15 months. CONCLUSION: Approximately one third of neuroradiologic abstracts presented at national meetings in 1993 were published in indexed journals. This rate is lower than that of abstracts from medical specialties other than radiology.

Complete duplication or extreme fenestration of the basilar artery.

We describe a 42-year-old man with complete duplication or extreme fenestration of the basilar artery. We review the developmental anatomy and embryology and discuss the possible clinical implications and associated findings of this anomaly.

Dural arteriovenous fistula of the cervical spine presenting with subarachnoid hemorrhage.

We describe a case of dural arteriovenous fistula (DAVF) presenting with subarachnoid hemorrhage (SAH). The diagnosis of DAVF was based on spinal angiography. A review of the literature revealed that five of 13 previously reported DAVFs of the cervical spine were accompanied by SAH. SAH has not been observed in DAVFs involving other segments of the spinal canal.

Endovascular treatment of experimental aneurysms by use of biologically modified embolic devices: coil-mediated intraaneurysmal delivery of fibroblast tissue allografts.

BACKGROUND AND PURPOSE: Our long-term goal is to improve intraaneurysmal fibrosis after aneurysm embolization, by implanting exogenous fibroblasts, using platinum coils. For the current project, we tested two hypotheses: 1) that exogenous, fluorescence-labeled rabbit fibroblast allografts remained viable and proliferated within rabbit carotid arteries, and 2) that these fibroblast allografts could be reliably implanted into experimental aneurysms by use of platinum coils. METHODS: Part 1. New Zealand White rabbit synovial fibroblasts obtained from a commercial vender were labeled with a fluorescent membrane marker. The common carotid arteries of New Zealand White rabbits were surgically exposed, ligated proximally and distally, and entered with 22-g angiocatheters. Through the angiocatheter we injected either phosphate-buffered saline-containing fluorescence-labeled fibroblasts (treatment vessels) or saline only (control vessels). The wounds were closed, and the subjects were kept alive for various time points up to 2 weeks. After sacrifice, the carotid artery segments were resected, processed for frozen-section histologic examination, and evaluated using epifluorescent microscopy and hematoxylin and eosin staining. Cell viability and proliferation were determined by comparing the treatment versus control vessels. Part 2. A) Fluorescence-labeled cells were grown in culture on platinum coils, which were then exposed to systemic arterial flow in the rabbit thoracic aorta for various lengths of time up to 40 minutes. The coil segments were then examined using fluorescent microscopy and the presence and relative amount of cells remaining on the coil were documented. B) Experimental aneurysms in rabbits were embolized with control platinum coils (n = 9) and platinum coils bearing rabbit synovial fibroblasts that were grown onto the coils in culture prior to implantation (n = 9). Subjects were sacrificed 3, 7, and 14 days after coil implantation. Histologic samples were studied to assess the presence or absence of nucleated cells within and around coil winds in order to determine whether fibroblasts had been successfully implanted into aneurysms. Data were evaluated using the chi-square test for statistical significance. RESULTS: Part 1. Fluorescence-labeled cells were examined in the treatment carotid artery segments and results were recorded at all time intervals. The treatment vessel segments showed evidence of progressive cellular proliferation, leading to complete vessel fibrosis at 2 weeks. Conversely, control vessel segments were filled predominately with unorganized thrombus at each time interval. Part 2. A) Numerous labeled fibroblasts remained adherent to the coil despite prolonged exposure to systemic arterial flow. B) Fibroblasts were seen adjacent to or within the central lumen of coils in eight (88%) of nine aneurysms treated with cell-bearing coils. Nucleated cells were not present in any of the nine control coil subjects. This represented a statistically significant difference (P < .001). CONCLUSION: Fibroblast allografts remain viable and proliferate in the vascular space in rabbits. Furthermore, these same fibroblasts, after seeding onto platinum coils in culture, remain protected within the lumen of the coils and are retained within the coil lumen even after prolonged exposure to arterial blood flow. Coils can be used to deliver viable fibroblasts directly into experimental aneurysms successfully. These findings indicate that coil-mediated cell implantation is feasible and may be a potential method of increasing the biological activity of embolic coils.

Hyperperfusion syndrome with hemorrhage after angioplasty for middle cerebral artery stenosis.

Hyperperfusion syndrome is a well-documented complication of carotid endarterectomy, as well as internal carotid artery angioplasty and stent placement. We report a similar complication after distal intracranial (middle cerebral artery [MCA] M2 segment) angioplasty. To our knowledge, this is the first report of hyperperfusion syndrome after intracranial angioplasty of a distal MCA branch.

Parent vessel occlusion for vertebrobasilar fusiform and dissecting aneurysms.

BACKGROUND AND PURPOSE: Previous reports of outcome with permanent vessel occlusion (PVO) for large, giant, or fusiform aneurysms in the posterior circulation have been limited. We undertook this study to evaluate the perioperative (within 30 days) and follow-up outcomes for patients treated with permanent occlusion of the vertebral artery for vertebrobasilar fusiform and dissecting aneurysms. METHODS: Thirteen consecutive patients were studied. Two groups were defined for the study. Group I patients underwent PVO to achieve complete thrombosis of the aneurysm. Group II patients underwent PVO to reduce flow to the aneurysm where complete thrombosis was not desirable. Modified Rankin scores were obtained at presentation and at follow-up (follow-up range, 1-76 months; mean, 22.0 months). RESULTS: All group I aneurysms were shown to be thrombosed on the angiograms obtained at the immediate follow-up examinations. Improvement in outcome scores was achieved by all group I patients. Improvement in Rankin scores after endovascular treatment was statistically significant (P =.026). All group II patients had complete occlusion of the vertebral artery; however, continued filling of the fusiform aneurysm was still observed. Four patients in group II died during the follow-up period. Two of these deaths were attributable to the aneurysms. Of the remaining three patients, two experienced clinical worsening and one remained stable. CONCLUSION: In this series, PVO for chronic fusiform and acute dissecting aneurysms of the vertebrobasilar system proved to be a useful therapeutic endovascular technique. Long-term outcomes suggest that patients with aneurysms involving only one vertebral artery, where complete thrombosis can be achieved, have better clinical outcomes than those who have aneurysms involving the basilar artery or both vertebral arteries, where complete thrombosis cannot achieved by using PVO.

Ion implantation and protein coating of detachable coils for endovascular treatment of cerebral aneurysms: concepts and preliminary results in swine models.

OBJECTIVE: Complete anatomic obliteration remains difficult to achieve with endovascular treatment of wide-necked aneurysms using Guglielmi detachable platinum coils (GDCs). Ion implantation is a physicochemical surface modification process resulting from the impingement of a high-energy ion beam. Ion implantation and protein coating were used to alter the surface properties (thrombogenicity, endothelial cellular migration, and adhesion) of GDCs. These modified coils were compared with standard GDCs in the treatment of experimental swine aneurysms. METHODS: In an initial study, straight platinum coils were used to compare the acute thrombogenicity of standard and modified coils. Modified coils were coated with albumin, fibronectin, or collagen and underwent Ne+ ion implantation at a dose of 1 x 10(15) ions/cm2 and an energy of 150 keV. Coils were placed in common iliac arteries of 17 swine for 1 hour, to evaluate their acute interactions with circulating blood. In a second study, GDCs were used to treat 34 aneurysms in an additional 17 swine. GDCs were coated with fibronectin, albumin, collagen, laminin, fibrinogen, or vitronectin and then implanted with ions as described above. Bilateral experimental swine aneurysms were embolized with standard GDCs on one side and with ion-implanted, protein-coated GDCs on the other side. The necks of aneurysms were evaluated macroscopically at autopsy, by using post-treatment Day 14 specimens. The dimensions of the orifice and the white fibrous membrane that covered the orifice were measured as the fibrous membrane to orifice proportion. Histopathological evaluation of the neck region was performed by light microscopy and scanning electron microscopy. RESULTS: Fibronectin-coated, ion-implanted coils showed the greatest acute thrombogenicity (average thrombus weight for standard coils, 1.9 +/- 1.5 mg; weight for fibronectin-coated coils, 8.6 +/- 6.2 mg; P < 0.0001). By using scanning electron microscopy, an intensive blood cellular response was observed on ion-implanted coil surfaces, whereas this was rare with standard coils. At Day 14, greater fibrous coverage of the necks of aneurysms was observed in the ion-implanted coil group (mean fibrous membrane to orifice proportion of 69.8 +/- 6.2% for the ion-implanted coil group, compared with 46.8 +/- 15.9% for the standard coil group; P = 0.0143). CONCLUSION: The results of this preliminary experimental study indicate that ion implantation combined with protein coating of GDCs improved cellular adhesion and proliferation. Future application of this technology may provide early wound healing at the necks of embolized, wide-necked, cerebral aneurysms.

Transforming growth factor beta-coated platinum coils for endovascular treatment of aneurysms: an animal study.

OBJECTIVE: To test the hypothesis that coating platinum coils with transforming growth factor beta (TGFbeta) would improve the cellular proliferation within experimental aneurysms relative to uncoated coils. MATERIALS AND METHODS: Elastase-induced saccular aneurysms were created in 12 New Zealand White rabbits. These aneurysms were embolized with platinum coils, either "control" (unmodified) coils or "test" (coated with TGFbeta) coils. Subjects were killed either 2 weeks (n = 3, control; n = 3, test) or 6 weeks (n = 3, control; n = 3, test) after embolization. Aneurysm tissue was embedded in plastic, sectioned, and stained with hematoxylin and eosin. The thickness of tissue covering the coils at the coil-lumen interface was measured by use of a digital microscope, and was compared between groups by use of the Student's t test (P < or = 0.05). RESULTS: Two-week implantation samples demonstrated mean thickness of tissue overlying TGFbeta-coated coils of 36+/-15 microm and mean thickness of overlying control coils of 3+/-5 microm, indicating significantly thicker tissue growth covering test versus control coils (P = 0.02). Six-week implantation samples demonstrated mean thickness of tissue overlying TGFbeta-coated coils of 86+/-74 microm versus mean thickness overlying control coils of 37+/-6 mu; this difference did not reach statistical significance (P = 0.30). Thickness of tissue covering TGFbeta-coated coils did not change significantly from 2 to 6 weeks (P = 0.31). Tissue thickness over control coils increased significantly between 2 and 6 weeks (P = 0.002). CONCLUSION: TGFbeta-coated platinum coils undergo earlier cellular coverage than standard platinum coils, but differences in coverage between coated and control coils are no longer present at later time points. These data suggest that improvements in intra-aneurysmal cellular proliferation resulting from coil modifications, although significant in the early postembolization phase, may dissipate over time.

Magnetic resonance imaging in the evaluation of patients for percutaneous vertebroplasty.

Osteoporosis and osteoporotic compression fractures of the vertebral bodies are major health problems facing women and older people of both sexes. In the last several years, percutaneous vertebroplasty has been developed as a treatment for pain caused by vertebral body compression fractures and primary or metastatic neoplasms. A large part of the success of this procedure depends on correct patient selection. As such, magnetic resonance imaging (MRI) plays a vital role in this process. In this review, the clinical evaluation of patients considered for vertebroplasty, the role of MRI in the pretreatment process, the postvertebroplasty appearance of the spine on MRI, and the future applications, such as real-time guidance with MR imaging, will be discussed.

Perfusion imaging of the human lung using flow-sensitive alternating inversion recovery with an extra radiofrequency pulse (FAIRER).

Pulmonary perfusion is an important parameter in the evaluation of lung diseases such as pulmonary embolism. A noninvasive MR perfusion imaging technique of the lung is presented in which magnetically labeled blood water is used as an endogenous, freely diffusible tracer. The perfusion imaging technique is an arterial spin tagging method called Flow sensitive Alternating Inversion Recovery with an Extra Radiofrequency pulse (FAIRER). Seven healthy human volunteers were studied. High-resolution perfusion-weighted images with negligible artifacts were acquired within a single breathhold. Different patterns of signal enhancement were observed between the pulmonary vessels and parenchyma, which persists up to TI = 1400 ms. The T1s of blood and lung parenchyma were determined to be 1.46s and 1.35 s, respectively.

Posterior inferior cerebellar artery aneurysms associated with posterior fossa arteriovenous malformation: report of five cases and literature review.

BACKGROUND: The association of posterior inferior cerebellar artery (PICA) aneurysms with posterior fossa arteriovenous malformation (AVM) is uncommon. Over the past 3 years, five patients with this condition were treated at this institution. A review of the clinical history of these and other reported cases has illuminated common threads in the presentation, treatment, and outcome of these lesions. METHODS: The findings of 27 patients (5 from our institution and 22 from the medical literature) with PICA aneurysms associated with AVMs were reviewed. RESULTS: Eighty-four percent of individuals presented with sub-arachnoid hemorrhage (SAH); 89% of these episodes resulted from aneurysm rupture documented by either intraoperative inspection or autopsy. All aneurysms were located on a feeding artery to the AVM, and 81% originated from distal portions of PICA. The majority of patients presented with Hunt & Hess grade I SAH; all patients who presented with hemorrhage were treated surgically. Surgical strategy was directed both to secure the aneurysm and to resect the AVM during the course of a single procedure. Although four individuals either died on admission or in the perioperative period, overall outcome was excellent or good in 82% of patients. CONCLUSIONS: PICA aneurysms associated with AVMs most often involve the distal segments of the artery. Patients usually present with SAH secondary to aneurysmal rupture. Surgical clipping of the aneurysm and excision of the AVM is possible in a single procedure with minimal morbidity. Overall prognosis is favorable in 80% of the cases.

Cerebral atrophy in Cushing's disease.

BACKGROUND: Cushing's disease causes significant pathological changes throughout the body as a result of elevated cortisol levels. Very few systematic investigations have focused on the morphologic effects of hypercortisolism on the central nervous system. The validity of using premature cerebral atrophy as a diagnostic tool for Cushing's disease remains unknown. METHODS: This study includes 63 patients with Cushing's disease who were evaluated and treated at the University of Virginia Medical Center. Radiologists randomly compared these individuals with age- and sex-matched controls in a blinded protocol, assessing the degree of cerebral atrophy on computed tomography and magnetic resonance scans. RESULTS: Patients with Cushing's disease showed significant premature atrophy when compared with controls. This trend continued after subdividing the groups based on age and duration of symptoms except in the following groups: age greater than 60, duration of symptoms less than 1 year, and symptoms lasting between 4-5 years. CONCLUSIONS: Excluding the three aforementioned groups, the hypercortisolemic state manifested in patients with Cushing's disease promotes the premature development of cerebral atrophy, which can be identified on routine radiologic imaging and may assist in the clinical diagnosis of the condition.