[Death of an infant following 'craniosacral' manipulation of the neck and spine]

A healthy 3-month-old girl died after manipulation of the cervical and thoracolumbar spine by a so-called craniosacral therapist. During persistent forced deep flexion of the neck and spine, the infant developed faecal incontinence, atonia and apnoea followed by an asystole. A physical examination, additional MRI studies and an autopsy indicated that the infant probably died as a consequence of local neurovascular lesions of the cervical spine or a mechanically-induced respiratory problem. This is the second reported case of an infant dying after forced manipulations of the neck. Until there is scientific evidence for the effectiveness and safety of forced manipulations of the vertebral column, we advise against this treatment in neonates and infants.

Time-of-flight magnetic resonance angiography in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils

The purpose of this study was to evaluate time-of-flight magnetic resonance angiography (MRA) in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils (GDCs). From January 1998 to January 2002 27 MRA and intra-arterial digital subtraction angiography (IADSA) examinations were analyzed for residual aneurysms and arterial patency following GDC placement. A total number of 33 intracranial aneurysms was analyzed, including 18 located in the posterior circulation. The MRA analysis was based on source images in combination with maximum intensity projections. The IADSA was used as the reference standard. Two aneurysms were excluded from evaluation, because of susceptibility artefacts from other aneurysms, which were clipped. Sensitivity and positive predictive values of MRA in revealing residual aneurysms were, respectively, 89% and 80%. Specificity in ruling out remnant necks and residual flow around coils was, respectively, 91% and 97%, with a negative predictive value of, respectively, 95% and 100%. Specificity and negative predictive value of MRA for arterial occlusion were, respectively, 87% and 100% for the parent arteries and, respectively, 85% and 100% for the adjacent arteries. MRA is a reliable diagnostic tool in the follow-up of GDC treatment, and it may replace IADSA in excluding residual flow around coils and aneurysmal necks and in ruling out arterial occlusion.

Magnetic resonance angiography in the selection of patients suitable for neurosurgical intervention of ruptured intracranial aneurysms

This study was aimed at establishing whether magnetic resonance angiography (MRA) can be applied to planning and performing surgery on ruptured intracranial aneurysms, especially in the early phase, without recourse to intra-arterial digital subtraction angiography (IA-DSA). From February 1998 to August 2001, in all patients presenting with a subarachnoid hemorrhage, MRA was performed first. A three-dimensional time-of-flight MRA protocol with T2-weighted coronal and axial images was used. If MRA demonstrated an aneurysm, surgery was undertaken. IA-DSA was limited to patients with negative or inconclusive MRA findings. We compared MRA images with operative findings in positive patients and with IA-DSA in negatives. IA-DSA was considered the gold standard when MRA findings were inconclusive. In this study, 205 consecutive patients (mean age 52.7 years, 69% women) were included. In 133 patients (64.9%) MRA demonstrated an aneurysm, directly followed by neurosurgical intervention. In 33 patients (16.1%) MRA findings were categorized as inconclusive. In 39 patients (19.0%) MRA results were negative. No false-negative ruptured aneurysms were selected by MRA. In only one patient surgical intervention was performed based on false-positive MRA findings. MRA can replace IA-DSA as a first diagnostic modality in the selection of patients suitable for surgical treatment of ruptured intracranial aneurysms.

The oculocerebrocutaneous (Delleman-Oorthuys) syndrome

We describe two cases of the so-called oculocerebrocutaneous syndrome, also known as the Delleman-Oorthuys syndrome. Both patients had characteristic congenital anomalies of the orbit, central nervous system and skin. The ocular and cerebral lesions were studied with CT and MRI.

Tuberculous meningitis in native Dutch children: a report of four cases

Although it is believed that in the western countries tuberculosis is a disease confined to high-risk groups such as immigrants, we describe four cases of tuberculous meningitis (TBM) in native Dutch children. The inverse relation between the delay in starting therapy and the clinical outcome makes early diagnosis of TBM essential. The often non-specific presenting symptoms and laboratory results, the time-consuming character of cultures and the unfamiliarity of western medical staff with the disease all may contribute to a delay in diagnosis of TBM. We believe that especially gadolinium-enhanced MRI or contrast-enhanced CT can be very helpful in the early diagnosis. Although not specific, hydrocephalus and basal meningeal enhancement on MRI or CT, together with the clinical suspicion can suggest the diagnosis to such an extent that there is enough reason to start antituberculous treatment.

The value of ultrasound mammography in palpable breast masses

Between January 1987 and May 1988 a prospective study was carried out on 232 women with a palpable breast mass. They underwent physical examination, x-ray mammography and ultrasound mammography. The results of each study were interpreted independently by separate observers, and consensus was achieved. From all solid tumours histology was available. Compared to x-ray mammography, ultrasound mammography proved to be significantly (p less than 0.025) more sensitive in diagnosing malignant palpable breast masses (98.7% versus 86.8%). However there was no statistical significant difference in specificity between ultrasound mammography and x-ray mammography. Using ultrasound mammography we classified 9 histological proven malignant tumours as such which were negative on plain x-ray mammography. Despite the good results of ultrasound mammography in diagnosing palpable breast lesions it can never replace x-ray mammography in cases of malignancy, because the results of ultrasound mammography with non-palpable synchronous tumours with or without microcalcifications are poor. In some cases of benign lesions diagnosed with ultrasound mammography no x-ray mammography is necessary.

Bilateral spontaneous carotid-cavernous fistulas, associated with systemic hypertension and generalised arteriosclerosis: a case report

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