Prolonged course of meningitis due to an arachnoid cyst.

An infected arachnoid cyst was found in a child with bacterial meningitis and prolonged fever. Surgical drainage of the cyst resulted in rapid improvement.

Magnetic resonance imaging in tuberous sclerosis.

Twenty-five patients with tuberous sclerosis were studied with magnetic resonance imaging (MRI), and these findings were compared with those of computed cranial tomography (CCT) and with the clinical severity of the disease. Multiple high-signal MRI lesions involving the cerebral cortex are characteristic of tuberous sclerosis and probably correspond to the hamartomas and gliotic areas seen pathologically. These cortical lesions were only occasionally seen with CCT. The periventricular calcific lesions characteristic of tuberous sclerosis are better visualized with CCT than with MRI, but the larger periventricular calcifications produce low-signal MRI abnormalities. Seven patients had high-signal MRI lesions of the cerebellum; small calcific cerebellar lesions were also noted with CCT in three patients. As in earlier studies, no clear correlation was seen between the number of abnormalities visible with CCT and the clinical severity of the disease. By contrast, the more severely affected patients tend to have a higher number of cerebral cortical lesions detected with MRI. Thus, MRI may be useful in predicting the eventual clinical severity of younger children with newly diagnosed tuberous sclerosis.

Monocular blindness in nasopharyngeal cancer.

The sudden onset of painless monocular blindness was the initial manifestation of a nasopharyngeal cancer in a 78-year-old woman. Computerized cranial tomography demonstrated encasement of the optic nerve by tumor. Examination of the nasopharynx and paranasal sinuses is important in patients with primary neuro-ophthalmologic complaints.

Clinical and computerized tomographic study of hypertensive intracerebral hemorrhage.

Historical, neurological, and computerized tomographic findings were correlated in 32 patients with hypertensive intracerebral hemorrhage. The mortality figures given in standard texts appear to be too high; the more acceptable figure would seem to be approximately 40%. Special attention was given to intraventricular rupture, which complicated 62% of the cases. Sudden onset of coma appears to correlate with the presence of intraventricular rupture. The "ring sign," if looked for, will be seen in most cases of resolving intracerebral hematoma.

Detection of tuberous sclerosis in parents by magnetic resonance imaging.

We performed a detailed physical examination and MRI without gadolinium DTPA contrast in 60 couples with at least 1 child having tuberous sclerosis (TS). Eight parents had TS diagnosed by physical examination, family history, or various diagnostic procedures including MRI. Eight additional subjects and 6 control subjects had nonspecific high-signal white matter changes on MRI. MRI confirmed the diagnosis of TS in only 1 parent without physical findings of the disease, similar to the results of earlier studies using computed cranial tomography. CT may be less sensitive than MRI but is probably more specific for TS. Either CT or MRI may occasionally help substantiate the diagnosis of TS in a parent with few other findings. Both studies may need to be done in some parents to maximize the accuracy of genetic counseling.

The spectrum of growing skull fracture in children.

The genesis and complications of the growing skull fracture in children is discussed. Four patients are presented to illustrate the common and uncommon features of growing skull fractures. The need for complete radiological evaluation as well as the timing of follow-up examinations is stressed.

A comparison of brain imaging with gamma camera, single-photon emission computed tomography, and transmission computed tomography: concise communication.

We have evaluated the utility of a single-photon axial tomographic scanner (ECT) in brain imaging, using routine tracers in 238 patients. When compared with routine delayed gamma-camera images (DGCI), there was agreement in 191 negative studies and 39 positive studies. Four patients had positive DGCI and negative ECT studies, and four had positive ECT and negative DGCI. In the 102 patients in this series who also had transmission CT (TCT) studies, there were five who had positive emission studies and negative TCT, and 38 with an abnormal TCT and normal ECT. The ECT was occasionally helpful in distinguishing brain and skull metastases, in better portrayal of deep lesions, and in resolving equivocal DGCI findings. For the ECT to become clinically rewarding, however, we feel that it will need development of new tracers that will provide functional information in addition to that already attainable by routine gamma-camera images.

MRI of corpus callosal syndromes.

Six patients, 6 to 13 years old, with corpus callosal abnormalities diagnosed by electroencephalography or CT were studied with a 0.15 T MR imager to determine the effectiveness of MRI in evaluating midline anomalies. Spin-echo images in the coronal, axial, and sagittal planes were obtained in two patients with Aicardi's syndrome and partial agenesis of the corpus callosum, in one patient with Dandy-Walker syndrome, and in two patients with septooptic dysplasia. Inversion recovery and spin-echo images were obtained in one patient with lipoma of the corpus callosum. Partial agenesis of the corpus callosum was seen in septooptic dysplasia, an association that has not been reported previously in the radiologic literature. Direct sagittal and coronal MRI provided better anatomic visualization of the brain and ventricles than did reformatted CT. T1-weighted images are sufficient to diagnose and delineate the extent of midline cerebral abnormalities. The unique capability of direct sagittal imaging makes MRI the best procedure for evaluating corpus callosal and other midline abnormalities.

Neuroradiologic aspects of cerebral disseminated intravascular coagulation.

Six patients with neurovascular disseminated intravascular coagulation (DIC) illustrate the diversity of neuroradiologic changes in that condition. Emphasis is placed on the involvement of large cerebral vessels, especially as reflected by cerebral vein or sinus occlusions. The latter occurred in four of the six cases reported; deep or superficial veins, larger lobar draining veins such as the superficial middle cerebral vein, or large bore vessels such as the superior sagittal sinus or jugular bulb were involved. Radionuclide sinography or computed tomography (CT) was useful in revealing large vessel occlusions or their sequelae; in two cases CT showed focal hemorrhage in an unusual location. Although DIC has classically been envisioned as occurring within the arterial microcirculation, these cases attest to the occurrence of large vessel, especially venous, involvement in neurovascular DIC.

Chronic seizure disorders: contribution of MR imaging when CT is normal.

One hundred consecutive patients with complex partial seizures were studied by magnetic resonance (MR) imaging and computed tomography (CT). Thirty-four patients had seizures of more than 5 years' duration, yet neurologic examinations and previous pre- and postinfusion CT scans had been normal. MR imaging demonstrated surgical lesions of potentially therapeutic significance in four of these 34 patients. Two patients underwent surgery with removal of a thrombosed arteriovenous malformation and a glioma. Although CT has been found to detect structural abnormalities, its yield of therapeutically significant abnormalities has been low.

Left atrial myxoma with cerebral emboli.

Infarction of the central nervous system secondary to embolism from left atrial myxoma is a recognized phenomenon. However, myxoma as the source of an embolus may be overlooked if an index of suspicion is not present during the evaluation of the patient with a stroke without a known cause. We present a case report that illustrates some of the pitfalls and characteristic findings present in the evaluation of these patients. The magnetic resonance image of multiple cerebral aneurysms and infarction associated with this condition is presented along with a unique, arteriographically proven resolution of a fusiform cerebral aneurysm after the removal of the cardiac tumor. A review of published case reports suggests that, if the cardiac tumor is recognized and treated quickly, the ultimate prognosis, while uncertain, is usually good. However, because the potential exists for recurrence of the cardiac tumor, for enlargement of the cerebral lesions, or for late development of cerebral lesions, long term follow-up is mandatory and a vigorous work-up must be pursued if the patient again becomes symptomatic or develops central nervous system manifestations for the first time.

Thrombosed aneurysm of the vein of Galen.

Computed tomography in a 3 1/2-year-old boy with ataxia, lethargy, fever, vomiting, and increasing irritability revealed moderate hydrocephalus and a blood density mass lesion lying superior and posterior to the 3rd ventricle. On several of the sections, the blood density was greater in the dependent than in the superior portion of the mass. The average attenuation number within the mass was 40 EMI units. The infusion of contrast agent demonstrated capsular enhancement (a target sign), which was also demonstrated by angiography. The diagnosis, which was confirmed at operation, was thrombosis of an aneurysm of the vein of Galen. The massive thrombus was resected, but the aneurysm was not excised. The patient's recovery was uneventful.

The natural history of intracranial venous angiomas.

Cerebral venous angiomas are congenital anomalies of the intracranial venous drainage. Many believe that they are associated with a high risk of hemorrhage and neurological dysfunction, but newer neurodiagnostic imaging techniques are showing not only that they are more common than previously known but also that many have no associated symptoms. In this retrospective study, the natural history of venous angiomas was examined in 100 patients (48 males and 52 females) with radiographically identifiable lesions treated over a 14-year period. Information on the natural history of the lesion was obtained from clinical records and follow-up data. Imaging studies included angiography, computerized tomography, and magnetic resonance imaging. Angioma locations were classified as frontal (42 cases), parietal (24 cases), occipital (4 cases), temporal (2 cases), basal or ventricular (11 cases), cerebellar (14 cases), or brain stem (3 cases); 47 lesions were on the left side. Headache as a presenting symptom was common (36 patients) and often led to other radiographic studies, but this appeared to be related to the vascular lesion in only four patients. Other possibly related complications were hemorrhage in one patient, seizures in five, and transient focal deficits in eight. Fifteen patients had no neurological signs or symptoms. The mean patient age at last contact was 45.3 years (range 3 to 94 years). All patients have been managed without surgery. It is concluded that significant complications secondary to venous angiomas are infrequent and that surgical resection of these lesions and of surrounding brain is rarely indicated.

Jugular venography for evaluation of abnormalities of the skull base.

Jugular venography done to evaluate abnormalities at the base of the skull demonstrated three distinctly different patterns depending on whether there is occlusion, invasion, or growth with in the internal jugular vein. Improper technique results in a lack of intracranial dural sinus filling which may masquerade as venous occlusion. This problem is avoided by adequate neck compression along with proper volume and rate of delivery of contrast. Radiographically, an abnormal jugular vein at the base of the skull will show a concave defect in true occlusion, constriction or invasion of the vein by tumor, or tumor growth within the vein.

Magnetic resonance imaging in pediatric neurologic disorders.

We present our initial experience with magnetic resonance imaging (MRI) in 301 pediatric patients with a variety of neurologic disorders. MRI does not require ionizing radiation and can be done easily and safely in children. It is equal or superior to computed cranial tomographic (CT) scans in demonstrating most types of pediatric neurologic disorders. MRI is often superior to CT scans in demonstrating intracranial tumors, although both studies are usually abnormal in highly malignant tumors. No clear advantage was shown with either MRI or CT scans for fluid-filled intracranial lesions. Lesions of the brain stem and upper cervical region, such as Chiari malformation, are well delineated by MRI. Increased signal from the paranasal sinuses was frequently evident by MRI, but, in most instances, there was no clinical indication of sinus disease. Large arteries can be visualized as an area of diminished signal, and intracranial hemorrhage, dural sinus thrombosis, and cerebral infarction were demonstrated. The increased anatomic detail pictured by MRI allows the diagnosis of congenital defects, such as agenesis of the corpus callosum or septum pellucidum, that are not always apparent with CT scans. Although our experience with spinal cord lesions was not extensive, fluid-filled lesions within the cord can be reliably demonstrated.

Results of nuclear magnetic resonance with cerebral glioma. Comparison with computed tomography.

Our experience using nuclear magnetic resonance (NMR) in eight patients with abnormalities on computed tomography (CT) scans suggesting glioma is reported. Three patients underwent biopsies. Two patients had grade II astrocytomas. Difficulty was encountered confirming the diagnosis of astrocytoma on frozen sections in one patient, and permanent sections were required for diagnosis in the other. The third patient to undergo biopsy had a grade III anaplastic mixed glioma. Biopsy of subsequent patients with probable gliomas was not done because of the risk of producing neurological deficit. The NMR images suggest that lower-grade astrocytomas are well circumscribed, whereas higher-grade gliomas affect adjacent association bundles by direct extension of tumor cells or vasogenic edema.