Erdheim-Chester disease: 25-year history with early CNS involvement

We report a case of Erdheim-Chester disease (ECD) with a 25-year history following initial presentation with diabetes insipidus and brainstem involvement. The exceptionally long history is particularly notable, given that ECD is a life-threatening disorder and there is a recognised association between central nervous system involvement and poor outcome. The case is a timely reminder of the presenting features of the condition, given the emergence of potential new treatment options.

Ovarioleukodystrophy due to EIF2B5 mutations

Ovarioleukodystrophy-the co-occurrence of leukodystrophy and premature ovarian failure-is a rare presentation now recognised to be part of the clinical spectrum of vanishing white matter disease. We describe a woman with epilepsy and neuroimaging changes consistent with leukoencephalopathy who presented with non-convulsive status epilepticus after starting hormone replacement therapy in the context of premature ovarian failure. Genetic testing confirmed her to be a compound heterozygote for EIF2B5 mutations; the gene encodes a subunit of eukaryotic translation initiation factor 2B. Mutations in EIF2B1-5 result in vanishing white matter disease. We highlight the importance of ovarian failure as a diagnostic pointer to eukaryotic translation initiation factor 2B (eIF2B)-related ovarioleukodystrophy and present a brief literature review of ovarioleukodystrophy.

Endovascular treatment of 300 consecutive middle cerebral artery aneurysms: clinical and radiologic outcomes

BACKGROUND AND PURPOSE

There is controversy as to the best mode of treating MCA aneurysms. We report the results of a large endovascular series of patients treated at our center.

MATERIALS AND METHODS

This study was a retrospective analysis of a prospectively acquired data base. All patients with saccular MCA aneurysms treated between November 1996 and June 2012 were included. World Federation of Neurosurgical Societies grade, aneurysm site, size, and aneurysm neck size were recorded, along with clinical outcome assessed with the Glasgow Outcome Scale and radiographic occlusion assessed with the Raymond classification at 6 months and 2.5 years.

RESULTS

A total of 295 patients with 300 MCA aneurysms were treated including 244 ruptured aneurysms (80.7%). The technical failure rate was 4.3% (13 patients). Complete occlusion or neck remnant was achieved in 264 (91.4%). Complications included rupture in 15 patients (5%), thromboembolism in 17 patients (5.7%), and early rebleeding in 3 patients (1%). Overall permanent procedural-related morbidity and mortality were seen in 12 patients (7.8%). Of the ruptured aneurysms, 189 (79.4%) had a favorable clinical outcome (Glasgow Outcome Scale score, 4-5). A total of 33 patients (13.6%) died. On initial angiographic follow-up, aneurysm remnant was seen in 18 aneurysms (8.1%). A total of 13 patients (4.3%) were re-treated.

CONCLUSIONS

Our experience demonstrates that endovascular treatment of MCA aneurysms has an acceptable safety profile with low rates of technical failure and re-treatment. Therefore, coiling is acceptable as the primary treatment of MCA aneurysms.

Retained and fractured microcatheter: a cause of transient ischaemic attacks: endovascular management using carotid stents

A retained microcatheter is a rare complication of endovascular treatment of cerebral aneurysms. We describe such a case that was complicated by delayed microcatheter fracture within the internal carotid artery and subsequent thrombo-embolism resulting in transient ischaemic attacks. We also describe endovascular management of this complication through the use of several carotid stents.

Endovascular therapy for acute basilar artery occlusion: a review of the literature

Basilar artery occlusion is an infrequent form of acute stroke; clinical outcomes are heterogeneous, but the condition can be fatal. There is a lack of randomized controlled trial data in this field. Case series suggest that patients who are recanalized have much better outcomes than those who are not, and it is generally accepted that intra-arterial techniques achieve high rates of recanalization. Controversially, several studies, including a meta-analysis and registry-based investigation, that have compared intravenous thrombolysis (IVT) and intra-arterial treatment suggest similar outcomes. However, there are many potential sources of bias in each of these studies, precluding a firm conclusion. Indeed, there are many confounding factors that can influence the outcome including severity of presentation, site of occlusion, clot load, degree of collateral flow, timing of therapy, agent used for recanalization and dose of thrombolytic agent. Additionally, pretreatment infarct core imaging using diffusion-weighted imaging and the posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) scoring systems have been shown to predict outcome and therefore may be useful in selecting patients for aggressive therapy. Protocols combining intravenous agents such as glycoprotein IIb/IIIa receptor antagonists or thombolytics agents with intra-arterial techniques ('bridging' therapy) have shown encouraging improvements in neurological outcome and survival. Furthermore, initial case series describing the use of mechanical clot extraction devices or aspiration catheters suggest high rates of recanalization. What would be useful is a randomized trial comparing IVT, endovascular approaches and a combined IVT/endovascular approach. However, the small numbers of patients and multiple confounding factors are barriers to the development of such a trial.

Retreatment of previously embolized cerebral aneurysms: the risk of further coil embolization does not negate the advantage of the initial embolization

BACKGROUND AND PURPOSE

A significant minority of aneurysms treated by endovascular means undergo additional subsequent therapy to treat aneurysm recurrence. Our study was undertaken to determine the risk of additional coil embolization of aneurysms recurring following endovascular therapy.

MATERIALS AND METHODS

Patients were identified during a 10-year period from prospectively collated data bases at 2 different neuroscience institutions. Patient outcome was obtained from the data bases or the patient's neurosurgical records. Occlusion grade was assessed at the time of treatment and at follow-up angiography as complete, near-complete, or incomplete.

RESULTS

Of a total of 1834 aneurysms in 1631 patients, 100 aneurysms in 99 patients treated between January 1996 and December 2005 required additional coiling because of an enlarging remnant and subtotal occlusion. This comprised 6% of the patients treated and 8% of the total followed. Thromboembolic events complicated 3 retreatment procedures, but all 3 patients remain independent. Ninety-five patients were followed for 8-103 months (mean, 42.3 months) by conventional or MR angiography.

CONCLUSION

Coil embolization of aneurysm recurrences has a low complication rate and leads to satisfactory occlusion in most cases. The risk from additional coil embolization does not negate the advantage of the initial embolization.

Some patients with multiple sclerosis have neurovascular compression causing their trigeminal neuralgia and can be treated effectively with MVD: report of five cases

The role of trigeminal ganglion percutaneous injection and radio-frequency lesioning procedures for the treatment of trigeminal neuralgia (TGN) in multiple sclerosis (MS) is well established. There is general acceptance that microvascular decompression (MVD) cannot be an appropriate treatment due to the view that the underlying aetiology is a demyelinating plaque affecting the root entry zone of the trigeminal pathway. Recently, MR-imaging has been used in the preoperative investigation of this group of patients demonstrating that neurovascular compression can occasionally be the responsible mechanism and that MVD can be the treatment of choice. We present five cases with MS and TGN. All the patients had failed to respond to medical treatment or percutaneous procedures. Magnetic resonance imaging demonstrated evidence of neurovascular compression in four cases. All the patients underwent MVD. Postoperatively four of the five patients made an uncomplicated recovery, were pain-free and fully satisfied with the result (mean follow-up 38.75 months; range 8-59 months). One patient developed recurrent pain 1 week following surgery and went on to have a total sensory rhizotomy. TGN in MS can be caused by neurovascular compression, which may be identified on MR-imaging. MVD has offered satisfactory short-term outcome for at least 2 years and does not inflict sensory loss. Longer follow-up will determine whether the outcome in MS patients will be as successful as in the TGN patients who do not suffer from MS.

How accurate is magnetic resonance angiography in predicting neurovascular compression in patients with trigeminal neuralgia? A prospective, single-blinded comparative study

Ninety-two patients with trigeminal neuralgia (TGN) were investigated prior to posterior fossa surgery with magnetic resonance imaging (MRI) and contrast-enhanced magnetic resonance angiography (MRA). The preoperative investigation was matched to one consultant neuroradiologist (co-author) who was blinded to the side of symptomotology. The imaging results were compared with the operative findings in all patients. In 76 patients MRA showed present neurovascular compression in accordance with surgical findings. Eight cases had no compression either on MRA or intraoperatively. Eight predictions of no compression were false and there was no false positive. Based on surgical findings, the sensitivity of MRA was 90.5% and the specificity 100%. In 19 cases MRA predicted bilateral compression of the trigeminal nerves. Only two cases had clinically bilateral TGN. We conclude that MRA with gadolinium enhancement is an extremely sensitive and specific method for demonstrating compression in TGN. As a result posterior fossa surgery can be recommended with confidence, and microvascular decompression remains the treatment of choice for TGN at the authors' centre.

Middle cranial fossa arachnoid cysts: not always a benign entity

Arachnoid cysts are often discovered as incidental findings on cranial imaging. A rare manifestation is described in a child presenting acutely with symptoms and signs of raised intracranial pressure.

Pictorial review: MR imaging of neuronal migration anomalies

Neuronal migration anomalies form a spectrum of congenital brain malformations with a variety of clinical manifestations. The widespread use of MRI in the investigation of neurological symptoms, and particularly in the imaging of epilepsy, has made the correct recognition and interpretation of these disorders important. This pictorial summary describes the typical clinical features and the MR appearances of this group of conditions. For a more detailed review which includes pathological correlation, the reader should refer to an excellent article by Barkovitch and colleagues (Barkovitch A.J., Gressens P, Evrard P. Formation, maturation and disorders of brain neocortex.

Embolisation of recently ruptured intracranial aneurysms

Patients with subarachnoid haemorrhage due to the rupture of aneurysms unsuitable for craniotomy and clipping have been treated by coil embolisation within three weeks. Sixty nine of 75 consecutive patients were successfully treated. Procedure related complications occurred in 10 patients, resulting in permanent neurological deficits in three and one death (4.8%). The Glasgow outcome scores at six weeks were 53 grade 1, seven grade 2, four grade 3, and five grade 5. These results are comparable with surgical series despite a high proportion of aneurysms in the posterior cerebral circulation.

Spontaneous intracranial hypotension

The clinical features and radiological appearances of spontaneous intracranial hypotension are described in three patients and the medical literature is reviewed. Awareness of this condition and its differentiation from more sinister meningitic processes is important to avoid unnecessary invasive investigations and to allow prompt diagnosis and effective treatment.

Selective amygdalohippocampectomy for hippocampal sclerosis: postoperative MR appearance

PURPOSE

To analyze the anatomic consequences of selective amygdalohippocampectomy (AH) in patients with hippocampal sclerosis and to correlate the clinical outcome with the MR appearance.

METHODS

Seventeen patients were examined with clinical and neuropsychologic examination and cranial MR after AH (7 transcortical AH, 10 trans-Sylvian AH). The clinical and neuropsychologic outcomes after AH were compared with those of anterior lobectomy (ATL).

RESULTS

There was no significant difference in seizure cure between transcortical or trans-Sylvian AH and ATL. However, patients with left AH fared significantly better in terms of verbal IQ and nonverbal memory when compared with those with left ATL. Verbal memory and cognition were not significantly different in the two AH groups. Variable amounts of hippocampal and amygdala remnants were found in both AH groups and did not correlate with seizure cure. White matter change consistent with gliosis probably secondary to wallerian degeneration was demonstrated in the anterior temporal lobe to a mean distance of 4.5 cm after transcortical AH and to a lesser degree as a consequence of trans-Sylvian AH. Nine patients (53%) (4 transcortical All, 5 trans-Sylvian AH) demonstrated wallerian degeneration in the optic radiations after surgery. All had incomplete contralateral quadrantanopia.

CONCLUSIONS

There is more secondary damage to the temporal lobe after AH than was previously recognized. The extent of hippocampal and amygdala resection in AH do not seem to be directly related to seizure cure. Visual field defects are common in AH because of the anterior but variable course of the optic radiations

Thrombosis in giant basilar tip aneurysms during coil embolization

Two patients with giant basilar tip aneurysms underwent coil embolization, one with both platinum fiber and platinum Guglielmi detachable coils and the other with Guglielmi detachable coils only. In both cases, spontaneous intraaneurysmal thrombosis occurred outside the coil mass, presumably a result of disruption of the intraaneurysmal flow pattern.

The value of MRI in angiogram-negative intracranial haemorrhage

In one year, cerebral angiograms were performed for intracranial haemorrhage (ICH) on 334 patients. No cause for haemorrhage could be identified in 41 (12%), 30 of whom had predominantly subarachnoid (SAH) and 11 predominantly parenchymal haemorrhage (PH). These patients were prospectively examined by cranial MRI 1-6 weeks after the ictus. The MRI studies were positive in 7 patients (17%). In the 30 patients examined after SAH, 2 studies were positive, showing an aneurysm in one case and a brain stem lesion of uncertain aetiology in the other. In those examined after PH, cavernous angiomas were shown in 2, a tumour in 1 and a vascular malformation in another; useful diagnostic information was thus obtained in 36% of this group.

Unusual magnetic resonance and neuropathological findings in hemimegalencephaly: report of a case following hemispherectomy

Hemimegalencephaly is a rare disorder manifest by early epilepsy, mental retardation and hemiplegia. The neuropathology has been described in only 15 cases to date. The present case provides a further description of the pathology in a hemispherectomy specimen and shows unusual features, including cystic breakdown of the white matter possibly related to the long duration of the features, including cystic breakdown of the white matter possibly related to the long duration of the disease; the subject was 13 years older than previously documented cases. MRI findings were also unusual in showing mass effect and ventricular compression in the affected hemisphere, features not previously described in hemimegalencephaly.

Isolated atraumatic third nerve palsy: clinical features and imaging techniques

We have reviewed 34 consecutive patients imaged for an isolated third nerve palsy over a 2-year period. With pupil sparing the third nerve palsy was most often due to ischaemic microvascular disease. The commonest cause of a third nerve palsy with pupillary involvement was a posterior communicating artery aneurysm. Clinical features such as speed of onset, pain and completeness of palsy were not reliable in the diagnosis of either the nature or the location of the cause. Pupillary involvement was however often associated with a compressive lesion. Imaging along the whole course of the nerve is recommended for adequate evaluation.

Study of the anatomy of the extradural region using magnetic resonance imaging

We have studied magnetic resonance images of the lumbar spine of 39 subjects to examine the anatomy of the lumbar extradural region. The segmental nature of the posterior extradural region at each lumbar level may explain reports of easier cranial passage of extradural catheters introduced by the paramedian approach. This approach may thus provide a more reliable route for rapid introduction of an extradural catheter during the needle-through-needle, combined spinal-extradural technique.

The effective use of magnetic resonance imaging in the diagnosis of acoustic neuromas

The diagnostic approach to acoustic neuromas is complex but these tumours are infrequent in patients even with a suggestive clinical picture. Easy access to an efficient, reliable and cost effective investigation is desirable. Magnetic resonance imaging is now the imaging modality of choice and this paper shows that it may be used effectively as the sole investigation. T2-weighted (T2W) fast spin echo axial images taking 1 min 37 s to acquire were compared with T1-weighted (T1W) gadolinium-enhanced axial images, taking 5 min 11 s to acquire, in 157 patients. The T2W images were satisfactory alone in 43% of patients and allowed confident diagnosis of seven of the nine acoustic neuromas. Partial volume artefact and CSF flow artefact resulted in equivocal examinations in the remaining patients. Using both sequences in every patient, imaging time was 7 min 41 s and at least 40 patients could be examined in 1 day, thus ensuring efficient patient throughput. We suggest that T2W fast spin echo axial images be routinely obtained and that only when they are equivocal should T1W gadolinium-enhanced axial sequences be employed.

Case report: spontaneous thrombosis of a spinal dural AVM (Foix-Alajouanine syndrome)--magnetic resonance appearance

We describe a patient with a classical presentation of a spinal dural arteriovenous malformation which probably underwent spontaneous thrombosis. This is known as the Foix-Alajouanine syndrome. The diagnosis was not made in this patient until after cord infarction had occurred. The clinical and radiological features of spinal vascular malformations are reviewed because prompt treatment may halt or even reverse their neurological manifestations.

Renal transplant sonography: correlation of Doppler and biopsy results in cellular rejection

Seventy-one patients with allograft dysfunction had concomitant Doppler sonography and percutaneous biopsy. Forty-one had biopsy proven acute cellular rejection and eight had acute cellular rejection in combination with acute tubular necrosis. Real time ultrasonic appearance and various parameters of Doppler waveform were studied and compared with 30 controls who had a long period of stable function with no previous episodes of rejection or acute tubular necrosis (ATN). Morphological appearances were unhelpful in diagnosing rejection. A resistive index greater than 0.8 in the study group was highly specific for dysfunction but could not differentiate between acute rejection and ATN. However, two patients in the control group of normal transplants had a resistive index of 0.83. An early to mid diastolic notch was highly specific for acute rejection but of low sensitivity. It may be the only Doppler indication of cellular rejection and may be present when the resistive index is in the normal range.

The potential use of diuresis Doppler sonography in PUJ obstruction

Three cases of proven PUJ (pelvi-ureteric junction) obstruction in whom duplex Doppler sonography was performed are described. In one case, there was a duplex transplant kidney with PUJ obstruction of the lower pole moiety. The resistive index of an interlobar lower pole artery was markedly elevated compared to that of an artery in the upper unobstructed moiety. In the other two cases, the resistive index of interlobar arteries of native kidneys increased significantly following intravenous frusemide simultaneous with an increase in the degree of pelvicalyceal dilatation. It is proposed that diuresis Doppler sonography may provide additional diagnostic information in patients with PUJ obstruction, and that the method warrants further evaluation.

Osteomesopyknosis: a benign familial disorder of bone

A family with osteomesopyknosis is described. This condition is a rare benign bone dysplasia, characterized by patchy sclerosis predominantly involving the axial skeleton. The radiographic appearances may be confused with osteoblastic metastases, renal bone disease and other sclerosing bone disorders. As routine blood tests and isotope bone scans are normal in osteomesopyknosis, differentiation is readily achieved.

Case report: acute subdural haematoma--an unusual presentation of a meningioma

Acute subdural haemorrhage is usually the result of a head injury, but when it occurs without a history of trauma, an underlying cause must be suspected. An unusual case is described of an acute subdural haematoma in association with a parasagittal meningioma. This is a rare but serious complication of a meningioma and outcome depends upon prompt removal of the tumour.

Duplex and colour flow sonography in the diagnosis of post-biopsy arteriovenous fistulae in the transplant kidney

Arteriovenous fistulae are a common sequel to percutaneous biopsy of the transplant kidney. The majority close spontaneously, but a proportion progress and may require embolization or surgical closure. They are characterized by a very pulsatile (arterialized) venous flow. The arteries sometimes demonstrate a low resistive index and/or high velocities, but normal values may be encountered. On colour flow Doppler the most characteristic appearance is a mosaic of colour due to a combination of tissue vibration and turbulence.

Changes in arterial oxygen saturation during isotope perfusion scans using human macroaggregates of albumin

Sixty-three patients undergoing isotope ventilation/perfusion scintigraphy for suspected pulmonary embolism were monitored using pulse oximetry. Xenon inhalation had no adverse effect on arterial oxygen saturation. Fifty-seven per cent of patients demonstrated a drop in oxygen saturation of 2-10% within 5 min of injection of macroaggregates. Small changes in arterial oxygen saturation reflect larger changes in the arteriole partial pressure of oxygen. In 10 patients, oxygen saturation dropped to 91% and below, corresponding to an arterial pO2 of less than 60 mm Hg. The effect lasted up to 30 min and is thought unlikely to be simply due to arteriolar blockade. Falls in arterial oxygen saturation cannot be correlated with any specific pulmonary pathology and appear unlikely to be of any clinical significance in most patients.

Audit of nebuliser use

The use of nebulisers was assessed in four hospitals. Nebulisers were checked in use and medical and nursing staff were interviewed. All but one nebuliser was driven by 100% oxygen and only 3 of 111 interviewees preferred air for patients with hypercapnia. In 5 of 44 nebulisers in use, water was used as the dilutant. The calculated times for complete nebulisation of the solutions ranged from 3.5 to 117 min. The results of this survey illustrate a need for better education concerning the use of nebulisers in hospitals.