Progressive supranuclear palsy, computed tomography, and response to antiparkinsonian drugs.

Three patients with progressive supranuclear palsy demonstrated atrophy of the midbrain, pons, cerebellum, and cerebral hemispheres by computed tomography with horizontal, sagittal, and coronal reconstruction. Benztropine therapy resulted in improvement of speech and gait without significantly affecting the vertical gaze palsy.

Intraventricular craniopharyngioma.

An unusual case of an adult with a craniopharyngioma within the third ventricle is reported. The patient complained of headaches, had a history suggestive of diabetes insipidus, and presented with a severe dementia. A brain scan revealed the suprasellar midline lesion, and a pneumoencephalogram confirmed its location within the third ventricle. Therapy included partial surgical excision, followed by a ventriculoatrial shunt and radiation.

CT of subinsular infarction and ischemia.

A number of CT head scans, covering a 2-year period and showing a variety of distinct curvilinear subinsular lucent lesions, were collected and reviewed. Variations in extent of involvement, tendency toward bilateral symmetry, and clinical background allowed the lesions to be grouped into four general patterns, most of which, to our knowledge, have not been specifically described in the radiologic literature. This project was undertaken first to bring to the attention of those involved in interpretation of cranial CT images several patterns of injury they may not heretofore have been aware of and second to attempt to derive a specific etiology for each of the patterns described. Pattern 1, which appears as a distinct curvilinear lesion (sometimes cystic) apparently limited to the lateral aspect of the putamen, is thought to represent the residua of previous lateral striatal hemorrhage. Pattern 2, occurring in a markedly younger age group appears as relatively symmetrical bilateral subinsular lucencies, which in one case completely resolved. A specific etiology for this pattern remains uncertain. Acute demyelination, either secondary to a variant of anoxic leukoencephalopathy or to a limited form of diffuse encephalomyelitis, is postulated. A third pattern, which extends from generalized deep frontal white-matter lucency across the anterior limb of the internal capsule and tapering posteriorly in the subinsular area is thought to be on the basis of chronic ischemia similar to subcortical arteriosclerotic encephalopathy. The fourth pattern, occurring as a broad band of lucency extending from the frontal horn of the lateral ventricle and also tapering posteriorly is due to relatively proximal occlusion of the lateral lenticulostriate arteries.

The split notochord syndrome with dorsal enteric fistula.

Split notochord syndrome with dorsal enteric fistula is an extremely rare congenital anomaly that may be associated with meningomyelocele or meningocele, and genitourinary anomalies. This case presented with an additional finding of bladder exstrophy, raising the possibility of a relationship between this syndrome and the OEIS complex.

Delayed effects in the treatment of carotid-cavernous fistulas.

Carotid-cavernous fistulas may be classified into: (1) internal carotid, (2) external carotid, or (3) a combination of both. They may result from traumatic or spontaneous rupture of the carotid artery into the cavernous sinus. Intravascular embolization has become the treatment of choice for the management of carotid cavernous fistulas. The authors report the delayed effects after the treatment of carotid-cavernous fistulas with experience of 74 cases over the past 6 years. The delayed effects may be summarized as follows: (1) progressive spontaneous occlusion of the fistula after partial balloon embolization, (2) false aneurysms may decrease in size and be spontaneously sealed off, (3) transient and persistent third or sixth cranial nerve palsy may be seen in about 16% of 74 cases, (4) posttraumatic fibrosis with narrowing of the carotid artery may be apparent after total occlusion of the fistula, (5) a prematurely deflated balloon may be dislodged into the carotid artery or its branch, and (6) spontaneous obliteration of common channels from internal carotid artery may occur after total occlusion of external carotid channels in those cases with a combination of internal carotid- and external carotid-cavernous fistulas. Certainly the delayed effect will alter our future planning in the treatment of carotid cavernous fistulas.

Transvenous embolization of dural fistulas involving the cavernous sinus.

Because of the risks associated with arterial embolization of cavernous dural fistulas, we have sought an alternative method to promote fistula closure. Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas. All procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus. In five patients the inferior petrosal sinus was not angiographically demonstrable; however, embolization was still possible through this route in two patients. The embolic agents used were detachable balloons in one patient, coils alone in five, coils and liquid adhesives in four, coils plus silk sutures in one, silk sutures alone in one, and liquid adhesives alone in one. Nine patients had follow-up angiograms, which showed complete obliteration of the fistulas and complete resolution of related symptoms. One patient had complete resolution of clinical symptoms but refused follow-up angiography. Another patient had 50% decrease in fistula flow on the follow-up angiogram and improvement in clinical symptoms. Two patients had complete fistula obliteration after embolization and progressive improvement in symptoms but follow-up angiograms had not been obtained. Follow-ups ranged from 1 to 97 months (mean, 15 months). Two complications were related to this treatment. An embolic stroke followed transient placement of a balloon in the internal carotid in one patient, and a second patient developed transient visual loss when the venous outflow pathways were occluded before fistula closure. The fistula was immediately closed with complete recovery of vision. With recent advances in microcatheter and embolic agent technology, transvenous closure of cavernous dural fistulas is now possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult cerebellar medulloblastoma: imaging features with emphasis on MR findings.

PURPOSE: To describe the MR imaging features of cerebellar medulloblastoma in the adult. MATERIALS AND METHODS: The neuroimages and records of 15 adults with proved cerebellar medulloblastoma were retrospectively evaluated. In 12 patients, preoperative MR scans were reviewed; nine had Gd-DTPA-enhanced scans. RESULTS: Of the 12 tumors evaluated preoperatively, eight were hemispheric, two hemispheric-vermian, and two vermian. Tumor margins were well demarcated, except in three cases, two of which had large infiltrative tumors. In 10 cases, tumor extended to the brain surface, and in five of these, contiguity with the tentorium or cerebellopontine angle cistern was such than an extraaxial tumor was considered. The tumors were typically hypointense on T1 but a spectrum was seen on T2-weighted images. Enhancement ranged from minimal and patchy to marked. One tumor became isointense after Gd-DTPA. Other features included cystic changes, hemorrhage, exophytic invasion at the cerebellopontine angle, spinal cerebrospinal fluid seeding, intraventricular seeding, and bone metastasis. CONCLUSION: Although there is no pathognomonic MR appearance of adult cerebellar medulloblastoma, the finding of a well-demarcated, mild to moderately enhancing hemispheric mass involving the brain surface in a young adult is suggestive of medulloblastoma. Awareness that this tumor may resemble meningioma may avoid misdiagnosis and aid surgical planning.

Percutaneous transluminal angioplasty of the carotid artery.

Percutaneous transluminal angioplasty (PTA) is being extensively applied to treat arteriosclerotic lesions. However, this application has not been widely accepted for the treatment of carotid artery stenosis. Successful attempts to relieve cerebral ischemia from extracranial carotid arterial stenosis by PTA are reported. Twenty-seven patients with arteriosclerotic stenosis, fibromuscular disease, and Takayasu carotid arterial stenosis were treated by PTA. All anatomic carotid stenotic lesions were corrected without any neurologic complication. Follow-ups ranged from 3 months to 4 years without recurrent symptoms in any patient. These results may suggest that some patients with cerebral ischemia secondary to extracranial carotid artery stenosis may be treated safely and effectively by PTA.

Therapeutic embolization for vascular trauma of the head and neck.

Therapeutic embolization is an effective and relatively safe method for managing many cases of head and neck trauma. In the last 5 years, 78 traumatic vascular lesions--10 arterial transections and 68 arteriovenous fistula--were treated by intravascular embolization at four medical centers. Selection of embolic materials is discussed and different types of lesions are illustrated. Treatment was successful in every instance. Complications were limited to one case of cerebral infarction and two cases of temporary oculomotor weakness. The indications for embolization have widened beyond life-threatening hemorrhage alone, and continued improvement in techniques and embolic agents should see an increased use of this form of treatment.

Traumatic pseudoaneurysm of the cervical carotid artery: the value of arteriography.

A patient who sustained a gunshot wound to the neck and subsequent blunt trauma is presented. No angiogram was performed after the initial injury. Subsequently, the patient developed a cerebral embolus from a thrombus dislodged from a pseudoaneurysm of the cervical carotid artery, resulting in complete occlusion of the distal internal carotid artery. After antiplatelet therapy, the distal internal carotid artery recanalized, and the pseudoaneurysm occluded spontaneously. We stress the need for the use of arteriography in the initial evaluation of penetrating injuries to the neck and the utility of repeated arteriograms for further treatment planning as these traumatic lesions can change with time.

Septation in syringomyelia and its possible clinical significance.

A 3-year-old boy with a septated syrinx and several other dysraphic features is presented. The literature regarding the cause, diagnosis, and pathology of septation in syringomyelia is reviewed. This case raises two points. First, the septated pattern may be associated with an elevated pressure in the syrinx. Second, despite the septations, the syrinx may communicate freely.

Xanthogranulomas of the third ventricle.

Two patients with xanthogranuloma of the 3rd ventricle are described. In each instance the tumor obstructed the interventricular foramina and caused dilatation of the lateral ventricles and signs of increased intracranial pressure; computerized tomography demonstrated the dense, nonenhancing lesion in the anterior 3rd ventricle. The pathogenesis of these rare tumors is discussed. These cases affirm the need to consider xanthogranuloma in the differential diagnosis of anterior 3rd ventricle tumors in adults.

Diagnosis of cerebellopontine angle tumors with small quantities of air.

Difficulty in detecting small acoustic neuromas has encouraged us to study patients suspected of having a tumor by air cisternography augmented with computed tomography. Ninety patients were examined without complication. Five cubic centimeter of air was introduced via lumbar puncture and manipulated into the cerebellopontine angle cisterns. Scanning is commenced immediately. Filling of both internal auditory canals and identification of the neurovascular bundle in the cerebellopontine angle cistern was possible in all patients except those with tumors. The diagnostic accuracy, speed, and lack of morbidity have made this procedure the initial radiologic examination at our institution for patients suspected of having acoustic neuroma.

Spontaneous closure of a high-risk dural arteriovenous malformation of the transverse sinus.

The case of a 44-year-old woman with tinnitus of her left ear is presented. An arteriogram demonstrated a posterior dural arteriovenous malformation (AVM) on that side with drainage via dilated cortical veins into the superior sagittal sinus. No intervention was undertaken. When angiography was repeated 7 years later, no dural AVM was seen.

Diagnosis of empty sella with small amounts of air at computed tomography.

The incidental finding of an enlarged sella turcica on a skull roentgenogram may precipitate a tedious, expensive endocrinological as well as invasive radiological evaluation of an asymptomatic patient. Computed tomography and metrizamide cisternography have been suggested as alternatives to traditional pneumoencephalography. We have found the most direct and definitive study of the "empty sella" to be limited computed tomography after the introduction of a small amount of air by lumbar puncture. The diagnosis is made quickly without morbidity.

Coronal and sagittal reconstruction in computerised tomography.

As useful and dramatic as axial computed tomograms are, severe limitations have been encountered. Most of these involve the accurate location of masses and, as in angiography, projections in several planes are essential. Recent advances in both hard and softward allow three millimeter slice thicknesses at low radiation dosage. Coronal and sagittal reconstructions are practical and obtained with ease. The computerized tomogram is invaluable in complementing standard neuroradiological procedures and, in some cases, allows definitive diagnosis. This degree of accuracy is not possible without multiplane reconstructions.

Epidural venography in the diagnosis of lumbar disc disease.

Epidural venography is a simple and effective technic in the diagnosis of herniated intervertebral discs. The procedure may be performed in the outpatient department using percutaneous transfemoral catheterization. Our experience in 87 cases suggests that epidural venography is superior to Pantopaque myelography at the L5-S1 level, comparable to, and in some cases superior, at the L4-L5 level. The epidural venogram was abnormal in 33 cases. The findings were confirmed at operation in 25 of these. The remaining eight patients are being followed or are awaiting surgical treatment. Twenty of the 25 cases had had normal Pantopaque myelograms. Fifty-four of the 87 cases were considered to be normal.

Intracerebral hemorrhage from a middle meningeal arteriovenous fistula with a giant venous varix.

A patient with a congenital arteriovenous fistula between the middle meningeal artery and a cortical vein with a giant venous varix is described. The patient presented with an intracerebral hemorrhage that had been evacuated. Permanent cure of the fistula was achieved without morbidity by embolization with Ivalon particles.

Anticoagulants and intracerebral hemorrhage from an unsuspected meningioma.

A unique case of a patient with an undiagnosed convexity meningioma is presented. Hemorrhage into the tumor, following the administration of anticoagulant drugs for the treatment of thrombophlebitis, resulted in severe neurological defects and the eventual demise of the patient.

Subdural metastases from prostatic adenocarcinoma.

Adenocarcinoma of the prostate commonly metastasizes to lymph nodes and bones, with occasional visceral deposits; lesions in the brain are rare. Although leptomeningeal carcinomatosis secondary to prostatic tumor has been reported, discrete cranial dural metastases from prostatic adenocarcinoma have not been described previously. The case of a patient having a unique adenocarcinoma of the prostate with bone, lymph node, and subdural metastatic lesions is presented.