Cerebral infarction: shortcomings of angiography in the evaluation of intracranial cerebrovascular disease in 25 cases.

We studied the utility and limitations of conventional cerebral angiography in 25 patients with cerebral infarction unassociated with extracranial cerebrovascular disease during a 7-year period. In only one-third of cases was the angiogram diagnostic, and in a single case it altered the pre-angiogram diagnosis by revealing a previously unsuspected embolus. Among the cases clinically diagnosed as cerebral emboli, the 2 confirmatory angiograms were performed early (within 48 hours), and demonstrated medium-large or large vessel filling defects. Two-thirds of the negative angiograms in the embolic clinical category were delayed, but there was no statistically relevant predilection for specific vessel size involvement. The category, primary cerebral vasculopathy, comprised the largest group, 10 in all, and one-half had angiographic confirmation despite time delays. Angiographic recognition was dependent on a characteristic picture of vascular involvement, and not on timing or vessel size predilection. Mitral valve prolapse figured prominently in the clinical cases of vasculopathy of uncertain etiology, which contained a total of 4 cases. The 3 cases with nondiagnostic angiograms were all delayed and demonstrated nonspecific radiographic changes. Clinically, these cases demonstrated signs or symptoms of autoimmune dysfunction, raising the specter of primary cerebral vasculopathy as a cause of cerebral infarction, in contrast to recurrent cerebral emboli.

Cerebral hemisphere asymmetry in CT and functional recovery from hemiplegia.

Cerebral hemispheric asymmetries were assessed in relation to motor and functional recovery in nine patients with stroke. All were globally aphasic, assuring similar location and extent of lesion. Initial motor and functional ability were appraised from medical records and compared with neurologic and functional outcome. Frontal and occipital hemispheric widths and lengths were determined from CT. Patients were classified into three groups on the basis of mean combined asymmetry for width (typical asymmetry, atypical asymmetry, and equal symmetry). Patients with the most atypical cerebral asymmetries showed greater recovery than patients in other groups. Two patients with atypical mean occipital asymmetry (width) fared best functionally, whereas the patient who showed the greatest motor recovery had the most atypical mean occipital asymmetry (width). Cerebral asymmetries may contribute to recovery after stroke.

Progressive polyradiculopathy in acquired immune deficiency syndrome.

We studied three patients with acquired immune deficiency syndrome (AIDS) and progressive polyradiculopathy. Postmortem examination of one patient disclosed extensive necrosis, inflammatory infiltrates, and focal vasculitis of spinal roots. Typical cytomegaloviral (CMV), intranuclear, and intracytoplasmic inclusions were noted within enlarged endoneurial and endothelial cells. Progressive polyradiculopathy is an unusual complication of AIDS; CMV may be the causative agent in certain cases.

Visual neglect during intracarotid amobarbital testing.

The unilateral suppression of hemispheric function by sodium amobarbital may result in hemispatial visual neglect, as measured by performance on a random letter cancellation task. Our study not only investigates this hypothesis but also attempts to identify more precisely the anatomic locus of control for directed attention to extrapersonal space by correlating scanning performance with EEG activity. Forty-eight consecutive patients with epilepsy underwent preoperative intracarotid amobarbital tests. The results indicated that disruption of scanning and contralateral neglect occurred only after right-hemisphere suppression and seemed specifically related to changes in right frontal lobe EEG activity. This pattern of performance held not only for right-handed subjects, but also for those who were left-handed, and even for those who had right-hemisphere language dominance.

Primary amenorrhea and pseudoprolactinoma in a patient with primary hypothyroidism. Reversal of clinical, biochemical, and radiologic abnormalities with levothyroxine.

A 15-year-old girl presented with primary amenorrhea, galactorrhea, hyperprolactinemia and an enlarged pituitary gland. She proved to have primary hypothyroidism. Therapy with levothyroxine resulted in prompt induction of regular menses, normalization of hormone levels, and a reduction in the size of the pituitary. Although hypothyroidism is known to produce secondary amenorrhea, hyperprolactinemia, and pituitary enlargement, this is believed to be the first computed tomographic documentation of such a "pseudoprolactinoma" presenting as primary amenorrhea.

Meningioma in four patients with human immunodeficiency virus infection.

We describe four patients infected with the human immunodeficiency virus (HIV) who had development of meningiomas. In contrast to those in the general population who have meningiomas, all our patients were young men; the mean age was 40 years (range, 32 to 50). Their risk behavior for HIV was homosexuality (three patients) and intravenous drug use (one patient). The CD4+ cell count in each of the three homosexual men was less than 50/microL and was 280/microL in the drug user. Imaging studies showed enhancing lesions in three of the patients. Although each of these meningiomas could have occurred in otherwise normal young to middle-aged men, we speculate that the meningiomas may have grown in these HIV-infected hosts because of either loss of immune function or dysregulation of cytokines.

Rheumatoid arthritis of the cervical spine.

This article discusses the pathologic and radiologic changes in the cervical spine that occur with rheumatoid arthritis. The relevance of radiologic evaluation using radiographs, conventional tomography, myelography, computed tomography, computed tomography-myelography, and magnetic resonance imaging is discussed. Magnetic resonance imaging is the pre-eminent radiologic modality in the examination of cervical rheumatoid arthritis.

Degenerative disorders of the cervical spine.

Magnetic resonance imaging is the study of choice in patients with suspected degenerative discogenic disease. It is a sensitive diagnostic modality offering multiplanar imaging capability and excellent soft-tissue and spatial resolution without ionizing radiation. Physiologic information, primarily relating to water content, is provided as is a myelographic effect, without the risks of intrathecal contrast. Computed tomography remains a valuable adjunct in those patients with extensive bony degenerative changes.

MR angiography of the extracranial carotid arteries using a two-slab oblique 3-D acquisition.

PURPOSE: To describe an oblique, two-slab 3-D acquisition technique for MR angiography of the extracranial carotid arteries, an approach chosen to minimize saturation effects when the body coil is used as transmitter, as is often the situation when a dedicated neck coil is used as receiver. SUBJECTS: Five healthy subjects and 17 patients in whom carotid artery disease was suspected underwent MR angiography using the above technique. RESULTS: Flow contrast was much better than in direct sagittal acquisition. Comparisons between multislab transverse 3-D acquisition and the oblique approach showed that a greater length of the carotid arteries was depicted and scan time was less for oblique acquisitions. CONCLUSIONS: Use of oblique imaging is a simple and effective solution to the problem of coil-related saturation effects.

Neuroimaging and the lesion of multiple sclerosis.

In a patient with long-standing multiple sclerosis (MS), a double-dose delayed contrast-enhanced CT scan obtained during exacerbation revealed many areas of enhancement. Vigorous treatment with corticotropic hormone was followed by almost complete disappearance of these abnormalities. No areas of low attenuation were seen on a later unenhanced CT scan. Finally, MR imaging showed only a single area compatible with a plaque of MS. It is suggested that pathologic alteration of the blood-brain barrier seen in MS is not necessarily followed by demyelination and plaque formation. Restoration of the integrity of the blood-brain barrier may thus possibly prevent the formation of plaques in some MS patients, in particular if this can be accomplished early in the course of the exacerbation.

Fabrication of microballoons for interventional neuroradiology: preliminary report.

A simple and inexpensive method of making latex microballoons for neuroradiologic procedures is described. The balloons have been tested in experimental animals and used in human clinical procedures. Preliminary experience and results are presented.

Right hemisphere advantage for evaluating emotional facial expressions.

The ability to evaluate the intensity of emotional facial expressions was investigated in patients undergoing the intracarotid sodium amytal procedure. It was found that when the hemisphere non-dominant for language (usually right) was anesthetized, the patients' ratings of the intensity of emotional expressions in photographs were lower than baseline ratings of these expressions. Such an effect was not seen with anesthetization of the hemisphere dominant for language (usually left). Ratings of shades of gray (which served as control stimuli) showed no such effect. The findings are interpreted in terms of a right hemisphere superiority in the perception and evaluation of emotional expression.

Giant intracranial aneurysms of the anterior circulation: clinical characteristics and diagnosis by computed tomography.

The computed tomography (CT) characteristics and clinical features of giant (globoid) aneurysms of the anterior circulation are reviewed. These lesions appear on the CT scan as smoothly encapsulated ovoid masses, within which a partially patent lumen is seen after the infusion of iodinated contrast material. With careful analysis of the CT scan it may be possible to differentiate giant internal carotid artery, anterior cerebral artery, and middle cerebral artery aneurysms from other parasellar and hemispheric lesions.

Balloon occlusion of a recurrent carotid-cavernous fistula previously treated by carotid ligations.

A carotid-cavernous fistula recurred 16 years after a Hamby procedure. The recurrence was manifested by subarachnoid hemorrhage originating from dilated draining pial veins. The fistula was closed with a balloon catheter introduced through a patent remnant of the cervical carotid artery. Patients who have previously undergone Hamby trapping and embolization should be reassessed for an occult fistula that could predispose them to intracranial bleeding.

Transaqueductal migration of a neurocysticercus cyst. Case report.

The clearly documented transaqueductal migration of a solitary intraventricular neurocysticercus cyst is described. The cyst was fortuitously demonstrated on magnetic resonance imaging during migration through the aqueduct. The radiological appearance and clinical significance of this condition are discussed.

Image-guided endoscopic surgery: results of accuracy and performance in a multicenter clinical study using an electromagnetic tracking system.

Image-guided surgery has recently been described in the literature as a useful technology for improved functional endoscopic sinus surgery localization. Image-guided surgery yields accurate knowledge of the surgical field boundaries, allowing safer and more thorough sinus surgery. We have previously reviewed our initial experience with The InstaTrak System. This article presents a multicenter clinical study (n=55) that assesses the system's capability for localizing structures in critical surgical sites. The purpose of this paper is to present quantitative data on accuracy and performance. We describe several new advances including an automated registration technique that eliminates the redundant computed tomography scan, compensation for head movement, and the ability to use interchangeable instruments.

Embolization of solitary spinal metastases from renal cell carcinoma: alternative therapy for spinal cord or nerve root compression.

Four patients with a solitary vertebral metastasis from a renal cell carcinoma presented with acute spinal cord or nerve root compression. Because of the markedly hypervascular nature of the metastases it was decided to palliate the lesions by transarterial catheter embolization. The embolization reduced the venous blood pool within the tumors, resulting in progressive neurological improvement often lasting for 12 weeks or more. With such palliation, surgical decompression may be obviated, postponed, or at least made manageable.

Iopamidol in lumbar myelography.

Iopamidol is a new, nonionic, water-soluble contrast material currently undergoing clinical trials for intravascular and intrathecal use in Europe and the United States. In this study, 12 patients underwent lumbar myelography with this agent. For each subject, up to 12 mL of iopamidol (at 200 mg I/mL) was employed. The myelograms obtained were highly satisfactory. No serious adverse reactions were observed. The most common side effect--headache--occurred in seven patients. However, six of the seven headaches were mild and transient, and did not require treatment. Nausea occurred in two patients, back pain in two patients, hypotension and hypertension each in one patient. All of these reactions were mild and self-limited. Iopamidol appears to be a safe and conveniently used agent for lumbar myelography.