Results of four technical investigations in fifty clinically brain dead patients.

Fifty consecutive patients (aged 19-77 years, median 56 years) with primary cerebral diseases and the clinical signs of absent cortical and brainstem function were subjected to electroencephalography (EEG), brainstem acoustic evoked potentials (BAEP), extracranial Doppler ultrasonography (ECD) and arterial digital subtraction angiography (DSA). In the majority of cases the results of the technical tests agreed with the clinical signs and were suggestive of brain death. However, in one patient EEG revealed clear bioelectrical activity. In 6 cases, doubts existed about whether the EEG was isoelectric; in 3 of the 6 cases biological activity might have been present. In 31 of 42 patients ECD showed a typical pattern of intracranial circulatory arrest, in 9 of 42 ECD revealed a pattern suggestive of the cessation of cerebral blood flow. In four patients BAEP recordings compatible with brain death were recorded 2-3 days before intracranial circulatory arrest. In 2 patients with isoelectric EEG and absent BAEP arterial DSA demonstrated residual perfusion. The findings are discussed in view of the conceptional differences concerning brain death. It is concluded that the strict application of the concept of death of the whole brain requires angiographic demonstration of absent intracerebral blood flow.

[The scope and limitations in the demonstration of vessels by angiotomography; their relationship with contrast and size and between detail and direction of cut (author's transl)]. / Möglichkeiten und Grenzen der Gefässdarstellung im Angiotomogramm in Abhängigkeit von Detailkontrast und -grösse sowie von der Lagebeziehung zwischen Detail und Schichtrichtung

Experiments with models and post mortem angiograms have shown that the supposed advantages of angiotomography, such as determination of the depth of vessels, cannot be achieved with accuracy if there is repeated change in direction of the vessels. Blurring of superimposed vessels depends not only on their contrast and calibre, but also on their alignment in relationship to the direction of blurring. Vessels running in the direction of blurring produce undesirable shadows through a considerable depth, whereas vessels running across the direction of blurring are rapidly blurred if not in the selected plane. The demonstration of vessels running at right angles to the direction of blurring may at times be very difficult with simultaneous tomography. The clinical significance of this finding is pointed out.

[The effect of haemodynamic factors on tomograms during angio-tomography (author's transl)]. / Die Beeinflussung des Schichtbildes durch kreislaufdynamische Faktoren bei der Angiotomographie

Haemodynamic factors may influence the appearance of the tomograms during the performance of angio-tomography. Model experiments have shown that the thickness of section able to demonstrate vessels may depend on the relationship between vessel opacification and the timing of the cut. The clinical relevance of this is illustrated by tomographic studies of the renal and cerebral circulations.

[Experimental investigations into dissolution of size of detail and contrast in the angiotomograms]. / Experimentelle Untersuchungen zur Auflösung von Detailgrössen und -kontrasten in Angiotomogramm

A comparative investigation on the resolution of angio-tomography and cut-film changer technique, standard views and direct geometrical radiographic magnification were carried out, using a phantom. Catheters of varying calibre and contrast were tested. The most significant result was the finding that lower concentrations of contrast were necessary to demonstrate small vessels or catheters when using angio-tomography or magnification, than with conventional techniques. It was also shown that angio-tomography and a magnification technique are able to show smaller and less contrasty vessels.

[Angiographic features of liver echinococcosis (author's transl)]. / Angiographische Kriterien bei Leberechinokokkose.

From 1973 to 1978 13 cases of cystic hydatid disease and 15 cases of alveolar hydatid disease of the liver were diagnosed by angiography. The main diagnostic features of cystic hydatid disease of the liver are the following: "rim-sign", avascular areas, curved displacement of the arteries and stretching of the intrahepatic arteries. Multilocular hydatid disease of the liver shows tumor-like angiographic signs, such as atypical vascular formations, distensions, vascular irregularities, arterial stenoses as well as hepatosplenomegaly. Differential diagnosis in malignant liver diseases is often impossible, but early venous filling and arteriovenous shunts are not characteristic of multilocular hydatid disease of the liver. Particularly difficult is the interpretation in patients who have had previous surgery.

[The value of abdominal radiographs in the diagnosis of bromurea intoxication (author's transl)]. / Zur Wertigkeit der Abdomen-Leeraufnahme bei der Bromureid-Intoxikation.

Brom-substituted mono-urea hypnotics, which may be taken with suicidal intent, can be demonstrated radiologically. The value of routine abdominal x-rays in the recognition of intoxications has been examined at the University Clinic, Ulm, on patients admitted in 1976 and 1977. It has been shown that it is usually possible radiographically to indicate whether bromurea compounds have been taken in significant quantities, The bromurea has low solubility in the stomach and it is therefore possible to demonstrate the amount and type of substance present; this has some bearing on immediate treatment. Rapid removal of the toxic substance is so important for effective treatment that routine abdominal radiographs appear indicated for all life-threatening intoxications. Confusion with other opaque substances in practise is confined to preparations containing bismuth; although these are widely used, they have no significant toxicity.

[A comparison of ultrasound-Doppler sonography and angiography for stenosing lesions of supra-aortic vessels (author's transl)]. / Vergleichende Untersuchung ultraschall-dopplersonographischer und angiographischer Befunde bei stenosierenden Erkrankungen der supraaortalen Gefässe.

The ultrasonographic results of 158 patients with cerebro-vascular diseases were compared with the angiographic features. The results of the degree of the arterial stenoses correlated well in 66%. In 24% the ultrasonographic findings were false negative, in 10% they were false positive. With regard to the intentions of the centers of vascular surgery to operate as early as possible the ultrasound must be regarded as a screening method. The angiography is still necessary for the operation proceeding.

[Radiculo-tomography for lumbosacral myelography (author's transl)]. / Radikulotomographie bei der lumbosakralen Myelographie

The use of tomography can increase the value of lumbosacral myelography in certain circumstances. Post mortem studies have resulted in standardisation of the examination, which will combine optimal diagnostic information with the least amount of effort and with an acceptable amount of stress on the patient. 110 tomographic examinations were performed amongst 680 lumbosacral myelograms (Dimer X). On the basis of this experience, the value of this procedure is illustrated from various points of view and its indications are discussed.

[The appearances of chondropathia patellae on plain films (author's transl)]. / Zur Manifestation der Chondropathia patellae im Röntgennativbild.

The ability to diagnose chondropathia patellae on plain radiographs was studied in 64 patients in whom the disease had been confirmed either by operation or arthroscopy. All cases of stage III chondropathia were diagnosable by radiological examination; in stage I, 67%, and in stage II, 73% could be diagnosed. The diagnosis depends on the co-existence of marginal irregularities, irregularities of the subchondral bone lamellae, spotty diffuse demineralisation, marginal osteophytes, irregularities at the insertion of the quadriceps tendon and soft tissue changes such as joint effusions. These changes are best identified on the so-called "defilée" view. Disalignment of the axis of the patella and post-traumatic defects are of particular importance for the development of chondropathia, but in the present clinical material, the existence of dysplasia of the patella or of the femoral condyle was not associated with a demonstrable increase of chondromalacia.

[Cut-density in angiotomography (author's transl)]. / Die Schichtdicke bei der Angiotomographie

Tests show that the usual definition of cut-density is not applicable to angiotomography. New appropriate data for definition should take account of the relation between vessel and direction of cut and between timing of cut and contrast. These data cannot be obtained by examination in vivo. The concept of cut-density should be abandoned for inear angiotomography and replaced by that of layer of definition.

[The narrow spinal canal - medicolegal aspects (author's transl)]. / Der cervikal abnorm enge Spinalkanal -- Beobachtungen zur evtl. Bedeutung für die neurologisch Begutachtung

The constitutional anomayl of a narrow spinal canal was found in a neuroradiological department in 31 cases. The cervical stenosis can be defined in the following way: Inside diameter of cervical canal (anterior-posterior) in relation to diameter of vertebral body. In normal cases the quotient is over 1 - in pathological narrowing under 1. Clinical symptoms mainly appear from 45th year onwards, when reactive-degenerative changes increase the space problem. In wiplash injuries or other adequate cervical trauma 7 cases were seen and described with acute incomplete tetraplegia or/and multilocular lesions of cervical roots, resulting from cervical stenosis combined with degenerative changes in 6 patients. Myelography revealed multilocular deformities of the spinal subarachnoidal space in the abnormal narrow cervical canal. The referred cases were not complicated with forensic aspects. The prognosis quod sanationem was poor. A chronic cervical myelopathy results. Pretraumatic clinical alterations of cervical roots and/or the myelon in the referred cases were absent, existing in other patients. Predominantly men and hard working people with narrow cervical canal became ill. Early symptoms were pain in extremities. Dysesthesia and loss of sensation combined with signs of pyramidal lesion occured later. Defects in nerve roots sometimes overlayed the myelon symptoms. Unspecific CSF-Alterations were common. The EMG showed abnormalities in cases of root involvement. Operative treatment was tried to remove the reactive processes, but could not alter the constitutional anomaly. The resulting immobilisation of myelon and nerve roots involves in the case of trauma a direct mechanical lesion and secondary vascular complications via Arteria vertebralis, spinalis anterior and radicularis, namely in patients with degenerative alterations of the cervical spine, these including a further narrowing behind the constitutional anomaly. Our experience seems to recommend that more attention should be paid a cervical narrow spinal canal in medicolegal implications.

[Nuclear magnetic resonance imaging in the area of the cranial base]. / Kernspintomographie (MR) im Bereich der Schädelbasis.

Short TR (time repetition) and TE (time echo) images usually display pathologic structures unsatisfactorily. Tumors appear larger in MR than in computer tomography (CT). Additional examinations with intensive x-ray exposure are not necessary, as the better soft tissue contrast in MR allows for a distinct demarcation of the pathologic structure. T2-weighted images of brain stem angioma and pinealoma are not better than T1-weighted images. In the skull-base area, the sagittal plane best displays the anatomical-pathological relationship. The second plane is necessary for three-dimensional demarcation. On the second plane, the use of identical sequences is helpful, as the optical comparison of light intensity in pathologic tissue is easier.

Aneurysmal rupture during angiography.

A case of rupture, during angiography, of a right middle cerebral artery aneurysm with profuse hemorrhage into the subarachnoidal space is presented. Bleeding must have started between the two injections for the frontal and for the lateral carotidograms. The aneurysm that ruptured two days after a closed cerebral trauma was probably traumatic in origin.

Intra- and paraventricular arteriovenous malformations: symptomatology, neuroradiological diagnosis, surgical approach and postoperative results.

A series of 8 patients with para- and intraventricular arteriovenous malformations (AVM) is presented. Confirmed by histopathological examination or based upon their history all of them sustained recurrent intraventricular or intracerebral haemorrhages. Our results strongly recommend a surgical removal of these AVMs as a feasible and mandatory form of treatment. Conservative methods, e.g., embolisation or gamma beam irradiation leave the patient susceptible to rebleeding which often results in devastating neurological deficits. Total removal of the AVM with minimal surgical trauma was achieved in 7 patients under controlled hypotension and was facilitated by stereotactic guidance in two patients. Post surgical re-bleeding was not observed in any of our patients even though in one case only a subtotal resection of the angiomatous malformation was achieved. Based on our experience, we advocate an inspection of the lateral ventricle in order to avoid leaving any intraventricular portion of the vascular malformation behind. MRI investigation is recommended because the multiplanar images clarify the topographic-anatomic location and its relation to important surgical landmarks.

[Constitutional narrowing of the cervical spinal canal. Radiological and clinical findings]. / Konstitutionelle Enge des zervikalen Spinalkanals. Radiologische und klinische Befunde

A constitutional narrowing of the cervical spinal canal was seen in 31 patients with neurological disorders. The ratio of the inner diameter of the spinal canal to the diameter of the vertebral body was smaller than 1 (normal greater than 1). Clinical signs were observed from 45 years upwards where reactivedegenerative changes cause additional narrowing. The majority of patients were male, predominantly heavy manual labourers. There is often a trauma preceding. On myelography multilocular deformations of the spinal subarachnoid space and nerve roots are seen. On the mechanical narrowing of the spinal canal a vascular factor supervenes, caused by exostoses, intervertebral disc protrusions, and fibrosing processes. Clinically a chronic progressive spinal transection syndrome (cervical myelopathy) dominates besides a multilocular root involvement. Posterior column sensibility is predominantly lost. Pain in the extemities and the cervical column is an early symptom. Non-specific CSF changes occur frequently. In case of root involvement the electromyogram is pathological. The prognosis is bad. Operation can only remove reactive processes but not the constitutional anomaly.