Perinatal outcomes in lesbian couples employing shared motherhood IVF compared with those performing artificial insemination with donor sperm

STUDY QUESTION

In lesbian couples, is shared motherhood IVF (SMI) associated with an increase in perinatal complications compared with artificial insemination with donor sperm (AID)?

SUMMARY ANSWER

Singleton pregnancies in SMI and AID had very similar outcomes, except for a non-significant increase in the rate of preeclampsia/hypertension (PE/HT) in SMI (recipient's age-adjusted odds ratio (OR) = 1.9, 95% CI = 0.7-5.2; P = 0.19), but twin SMI pregnancies had a much higher frequency of PE/HT than AID twins (recipient's age-adjusted OR = 21.7, 95% CI = 2.8-289.4; P = 0.01).

WHAT IS KNOWN ALREADY

Oocyte donation (OD) pregnancies are associated with an increase in perinatal complications, in particular, preterm delivery and low birth weight, and PE/HT. However, it is unclear to what extent these complications are due to OD process or to the conditions why OD was performed, such as advanced age and underlying health conditions. Unfortunately, the literature concerning perinatal outcomes in SMI is scarce.

STUDY DESIGN, SIZE, DURATION

Retrospective study involving 660 SMI cycles (299 pregnancies) and 4349 AID cycles (949 pregnancies) assisted over a 10-year period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All cycles fulfilling the inclusion criteria performed in lesbian couples seeking fertility treatment in 17 Spanish clinics of the same group. Pregnancy rates of SMI and AID cycles were compared. Perinatal outcomes were compared: gestational length, newborn weight, preterm and low birth rates, PE/HT rates, cesarean section rates, perinatal mortality, and newborn malformations.

MAIN RESULTS AND THE ROLE OF CHANCE

Pregnancy rates were higher in SMI than in AID (45.3% versus 21.8%, P < 0.001). There was a non-significant trend to higher multiple rate in AID (4.7% versus 8.5%, P = 0.08). In single pregnancies, there were no differences between SMI and AID in gestational age (278 days (268-285) versus 279 (272-284), P = 0.24), preterm rate (8.3% versus 7.3%, P = 0.80), preterm <28 weeks (0.6% versus 0.4%, P = 1.00), newborn weight (3195 g (2915-3620) versus 3270 g (2980-3600), P = 0.296), low birth rate (6.4% versus 6.4%, P = 1.00), extremely low birth weight (0.6% versus 0.5%, P = 1.00), and the distribution of newborns by weight groups. Cesarean section rate, newborn malformation rate, and perinatal mortality were also similar in SMI and AID. Additionally, there was non-significant trend in hypertensive disorders to an increase in PE/HT among SMI (recipient's age-adjusted OR = 1.9, 95% CI = 0.7-5.2). Overall, perinatal data are consistent with what is reported in the general population. In twin pregnancies, the aforementioned perinatal parameters were also very similar in SMI and AID. However, SMI twin pregnancies had a very high risk of PE/HT when compared with AID (recipient's age-adjusted OR = 21.7, 95% CI = 2.8-289.4, P = 0.01).

LIMITATIONS, REASONS FOR CAUTION

Our data regarding the pregnancy course were obtained from information registered in the delivery report as well as from what was reported by the patients themselves, so a certain degree of inaccuracy cannot be ruled out. Additionally, in some parameters, there was up to 10% of data missing. However, since the methodology of reporting was the same in SMI and AID groups, one should not expect a differential reporting bias. It cannot be ruled out that the risk of PE/HT in simple gestations would be significant in a larger study. Additionally, in the SMI group allocation to the transfer of 2 embryos was not randomized so some bias is possible.

WIDER IMPLICATIONS OF THE FINDINGS

SMI, if single embryo transfer is performed, seems to be is a safe procedure. Double embryo transfer should not be performed in SMI. Our data suggest that the majority of complications in OD could be related more with recipient status than with OD itself, since with SMI (performed in women without fertility problems) the perinatal complications were much lower than usually described in OD.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received. The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

P–005 Magnetic-activated cell sorting in couples undergoing preimplantation genetic testing for aneuploidies (PGT-A) using autologous oocytes shows slightly lower aneuploidy rates compared to standard semen processing

Study question

Does the selection of non-apoptotic sperm via magnetic-activated cell sorting (MACS) reduce the aneuploidy rate of embryos from couples undergoing ICSI cycles with PGT-A using the patients’ own oocytes?

Summary answer

It does. The aneuploidy rate in the MACS group was 4.34% lower than the one obtained using semen samples processed according to standard clinical practice.

What is known already

MACS is a successful tool in eliminating proapoptotic sperm from a semen sample. However, the true effect of this technique on reproductive outcomes and the quality of the resulting embryos are a matter of controversy. Some studies report that its use improves the percentage of good quality blastocysts in women older than 30 years old compared to standard ICSI. Randomized clinical trials that compare MACS to a control sample consider parameters of embryo quality such as morphology at day 3 or day 5, symmetry of the blastomeres, blastocysts’ stage of expansion, but they do not consider embryo ploidy.

Study design, size, duration

Retrospective, multicentre, observational cohort study. 14,145 patients and 18,710 cycles were evaluated in the reference group. In the MACS group, 615 patients and 974 cycles were considered. Data were exported from cycles performed in Spanish IVIRMA clinics between January 2008 and February 2020.

Participants/materials, setting, methods

Unselected males in couples undergoing PGT-A cycles, then subdivided into male factor (MF) - total progressive motile sperm count lower than 5 million - and non-male factor (NMF) infertility. Statistical analysis performed using R v.4.0.0. Means were calculated and compared using two-tailed paired t-test, while proportions were compared using Fisher’s exact test and the chi-squared test and the appropriate correction for multiple comparisons. The aneuploidy rates for each group were compared using Fisher’s exact test.

Main results and the role of chance

In the control group 73,228 biopsied embryos, from which 71,439 were informative in the PGT-A. In the MACS group 3,919 biopsied embryos, from which 3,843 were informative. The aneuploidy rate, computed per informative embryo, was 68.87% (68.40%, 69.34%) in the reference group and 64.53% (62.43%, 66.64%) in the MACS group. Both comparisons were statistically significant (p-value ˂0.00001). According to these results, an embryo in the PGT-A programme using non-apoptotic sperm selected through MACS and autologous oocytes had a 5% less chance of being aneuploid than those embryos fertilised with standardly selected sperm (relative risk of 0.95 (0.91–0.98) p = 0.006769). Embryos conceived from NMF patients whose semen had been processed using MACS had a 4.27% lower aneuploidy rate than the reference (65.52% (63.16%, 67.88%) vs 69.79% (69.20%, 70.37%) respectively). This difference was statistically significant. Those embryos conceived using semen from patients with MF using MACS also showed a lower aneuploidy rate than the reference with MF (0.28% (55.48%, 65.08%) vs (64.94% (63.35%, 66.23%) respectively), although this difference was not statistically significant. Thus, the decrease in aneuploidy rate observed when comparing MACS and reference groups undergoing PGT-A cycles using autologous oocytes remained approximately the same in both MF and NMF semen samples.

Limitations, reasons for caution

The retrospective nature of the study subjects the data to biases or inaccuracies in their annotation in the clinics’ informatic platform from which they were exported. However, the statistical analysis aimed at controlling these biases as much as possible.

Wider implications of the findings: The vast amount of data compiled for this study confirms that the selection of non-apoptotic sperm through MACS slightly decreases the aneuploidy rate of embryos compared to semen samples processed according to the clinics’ standards. This would be interesting for patients who are considering undergoing PGT-A cycles in the future.

Trial registration number

Not applicable

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJECTIVE

To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment.

MATERIAL AND METHODS

A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed.

RESULTS

The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm.

CONCLUSIONS

SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Borrowing strength with nonexchangeable priors over subpopulations

We introduce a nonparametric Bayesian model for a phase II clinical trial with patients presenting different subtypes of the disease under study. The objective is to estimate the success probability of an experimental therapy for each subtype. We consider the case when small sample sizes require extensive borrowing of information across subtypes, but the subtypes are not a priori exchangeable. The lack of a priori exchangeability hinders the straightforward use of traditional hierarchical models to implement borrowing of strength across disease subtypes. We introduce instead a random partition model for the set of disease subtypes. This is a variation of the product partition model that allows us to model a nonexchangeable prior structure. Like a hierarchical model, the proposed clustering approach considers all observations, across all disease subtypes, to estimate individual success probabilities. But in contrast to standard hierarchical models, the model considers disease subtypes a priori nonexchangeable. This implies that when assessing the success probability for a particular type our model borrows more information from the outcome of the patients sharing the same prognosis than from the others. Our data arise from a phase II clinical trial of patients with sarcoma, a rare type of cancer affecting connective or supportive tissues and soft tissue (e.g., cartilage and fat). Each patient presents one subtype of the disease and subtypes are grouped by good, intermediate, and poor prognosis. The prior model should respect the varying prognosis across disease subtypes. The practical motivation for the proposed approach is that the number of accrued patients within each disease subtype is small. Thus it is not possible to carry out a clinical study of possible new therapies for rare conditions, because it would be impossible to plan for sufficiently large sample size to achieve the desired power. We carry out a simulation study to compare the proposed model with a model that assumes similar success probabilities for all subtypes with the same prognosis, i.e., a fixed partition of subtypes by prognosis. When the assumption is satisfied the two models perform comparably. But the proposed model outperforms the competing model when the assumption is incorrect.

Speciation and phylogeography of giant petrels Macronectes

We examine global phylogeography of the two forms of giant petrel Macronectes spp. Although previously considered to be a single taxon, and despite debate over the status of some populations and the existence of minimal genetic data (one mitochondrial cytochrome b sequence per form), the current consensus based on morphology is that there are two species, Northern Giant Petrel M. halli and Southern Giant Petrel M. giganteus. This study examined genetic variation at cytochrome b as well as six microsatellite loci in giant petrels from 22 islands, representing most island groups at which the two species breed. Both markers support separate species status, although sequence divergence in cytochrome b was only 0.42% (corrected). Divergence was estimated to have occurred approximately 0.2mya, but with some colonies apparently separated for longer (up to 0.5 my). Three clades were found within giant petrels, which separated approximately 0.7mya, with the Southern Giant Petrel paraphyletic to a monophyletic Northern Giant Petrel. There was evidence of past fragmentation during the Pleistocene, with subsequent secondary contact within Southern Giant Petrels. The analysis also suggested a period of past population expansion that corresponded roughly to the timing of speciation and the separation of an ancestral giant petrel population from the fulmar Fulmarus clade.

Tropomyosin-induced arthritis in rats

OBJECTIVE

Immunization of rats with alpha-tropomyosin (TPM) led to arthritis, uveitis and dermatitis, typical features of Behçet's disease (BD). The present study characterizes the arthritic features of this animal model, not previously described.

METHODS

Lewis rats were immunized with bovine alpha-TPM and another group of rats was treated with neutralizing anti- tumor necrosis factor-alpha (TNF-alpha) antibodies.

RESULTS

Clinically more than 90% of the immunized rats developed severe acute arthritis 12 days after vaccination. Rats that were followed-up for 6 months had persistent inflammation of the leg joints. Histologic studies demonstrated predominant mononuclear infiltrations in the acute phase of arthritis; the chronic arthritic process resulted in cartilage and bone damage and abundant fibrosis which led to joint deformations. Male and female rats had a similar clinical course. Analysis of the splenocyte cytokine profile kinetics revealed a persistently high level of interferon-gamma (INF-gamma) and an increase in TNF-alpha secretion during the acute phase. Increasing levels of interleukin (IL)-10 heralded the decline in clinical arthritis. No IL-4 was detected. No arthritis was detected in the rats treated with anti-TNF-alpha antibodies.

CONCLUSION

The data indicates that alpha-TPM serves as an autoantigen to induce acute and chronic destructive arthritis in rats. This model is a TNF-alpha dependent autoimmune disease, with a Th1 cytokine profile.

Blocking of the placental immune-modulatory ferritin activates Th1 type cytokines and affects placenta development, fetal growth and the pregnancy outcome

BACKGROUND

Placenta immunomodulatory ferritin (PLIF) cDNA was recently cloned from the human placenta, where it is expressed in syncytiotrophoblast and decidual mononuclear cells. PLIF and its subcloned bioactive domain (C48), expressed in Escherichia coli, are immunosuppressive proteins and induce pronounced IL-10 production in vitro and in vivo.

METHODS AND RESULTS

PLIF serum level, measured by enzyme-linked immunosorbent assay, was elevated in pregnant mice throughout gestation and declined towards delivery. Blocking of PLIF activity by vaccination of mice with C48 prior to mating inhibited pregnancy development. Passive transfer of anti-C48 immunoglobulin (Ig) starting at 3.5-12.5 days post coitum (dpc) resulted in high rate of embryo resorption. Furthermore, treatment with anti-C48 Ig resulted in placental and embryonal growth restriction. At gestation day 13.5, growth retardation was especially notable in the placentae, while at 16.5 dpc it was pronounced in the embryos. Histopathological examination revealed that experimental placentae were globally hypoplastic and the labyrinth was strikingly pale and contained less maternal blood compared with control. Immune-activated spleen cells harvested at 13.5 dpc from anti-C48 Ig-treated pregnant mice secreted in vitro increased level of Th1 cytokines (IL-2, TNF-alpha, IL-12) and decreased level of Th2 cytokines (IL-10, IL-4, IL-5, IL-6) as compared with the level of the respective cytokines secreted by spleen cells from control pregnant mice.

CONCLUSION

This study provides the first in vivo evidence that PLIF plays a major role in placentation and embryonic growth.

[Common bilio pancreatic channel syndrome in adults]

BACKGROUND

The Common Channel Syndrome (CCS) is defined as the union of the biliary and pancreatic ducts outside of the duodenal wall with a common duct more than 15 mm long. It is classified morphologically in types 1 and 2, whether it is the biliary or the pancreatic duct the one that predominates. CCS is uncommon in Western countries. It is described particularly in children and has not yet been reported in Chile.

AIM

To report the frequency of CCS among patients subjected to endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

Between 1992 and 1998, 1860 ERCPs were performed for the diagnosis of biliary or pancreatic diseases.

RESULTS

In six patients (0.35%) a CCS was diagnosed (3 type 1 and 3 type 2). All patients presented with pain and three with jaundice. Four patients had a previous cholecystectomy, three due to cholelithiasis and one due to gallbladder cancer. A common bile duct resection and bilioenteric anastomosis was done in three patients with a favorable outcome. Two patients with an advanced age and one with a gallbladder cancer, were not operated.

CONCLUSIONS

CCS was found in 0.35% of patients subjected to an ERCP. It frequently presents in association with one or more bilio-pancreatic diseases: cholelithiasis, choledocolithiasis, cholangitis, pancreatitis and gallbladder cancer. Resection of the common bile duct and a bilio-enteric anastomosis is proposed as the surgical treatment.

Acceleration of autoimmune diabetes by cyclophosphamide is associated with an enhanced IFN-gamma secretion pathway

Cyclophosphamide (CY), an alkylating cytostatic drug, is known for its ability to accelerate a number of experimental autoimmune diseases including spontaneous diabetes in NOD mice. The mechanism(s) by which CY renders autoreactive lymphocytes more pathogenic is largely unknown, but it has been postulated that the drug preferentially depletes regulatory (suppressor) T cells. It has been suggested that in cell-mediated autoimmune diseases, Th2-like lymphocytes secreting IL-4 and/or IL-10 provide protection, while Th1-like cells secreting IFN-gamma are pathogenic. In this study, we analysed the effects of CY on autoimmune diabetes and cytokines in two mouse models: the spontaneous diabetes of NOD mice and the diabetes induced in C57BL/KsJ mice by multiple injections of low dose streptozotocin (LD-STZ). In both models, CY induced severe lymphopenia and accelerated the progression to hyperglycemia. This was associated with changes in splenic cytokine patterns indicating a shift towards the IFN-gamma-secreting phenotype. We provide here evidence that IFN-gamma producers are relatively resistant to depletion by CY and that Th0 clones can be shifted towards Th1. However, direct exposure of T lymphocytes to CY may not be a necessary condition for exacerbation of diabetes; NOD.scid mice treated with CY before adoptive transfer of NOD splenocytes developed diabetes at a higher rate than did controls. Thus, the acceleration of diabetes by CY seems to be a complex event, which includes the relatively high resistance of IFN-gamma producers to the drug, their rapid reconstitution, and a Th1 shift of surviving T cell clones.

Immunization with recombinant Trypanosoma cruzi ribosomal P2beta protein induces changes in the electrocardiogram of immunized mice

Molecular expression cloning techniques revealed that patients with severe chronic Chagas heart disease showed a strong humoral response against the cloned C-terminal portion of the Trypanosoma cruzi ribosomal P2beta protein, previously named JL5. The main linear epitope of this polypeptide was mapped to the 13 C-terminal amino acid sequence EEEDDDMGFGLFD (named R13), which is almost identical to the mammalian ribosomal P consensus sequence EESDDDMGFGLFD (named H13). Enzyme-linked immunosorbent assay measurements demonstrated that sera from patients with chronic Chagas heart disease presented a very specific anti-P humoral response with high anti-R13, but low H13 antibody levels. We attempted to develop an animal model that would reproduce, at least partially, two features of the human infection: (1) the serological pattern of the anti-P response, and (2) specific cardiac symptoms. To this effect, mice were immunized with T. cruzi P2beta recombinant protein. Immunization reproduced the typical anti-P antibody profile defined for chronic infections, but did not induce cardiac inflammatory lesions. However, it altered significantly the electrocardiograms of immunized mice. It is suggested that this assay represents a functional test for assessing the biological activity of antibodies against T. cruzi ribosomal P protein on cardiac muscle.

[Use of embolization in the treatment of pulsatile tinnitus secondary to dural arteriovenous fistula]

Three cases of dural arteriovenous fistula (DAVF) in patients who consulted for pulsatile tinnitus are reported. All were treated successfully by embolization. If DAVF is suspected, angiography of the carotid and vertebral arteries should be performed to confirm its presence and to identify sources of blood flow and venous drainage. If treatment is needed, embolization, surgery, or radiotherapy may be indicated either separately or in combination therapy. The numerous branches and site of the fistula make therapeutic embolization the procedure of choice for many cases.

Traumatic aneurysm of the basilar artery

We report a case in which a "false" aneurysm of the basilar artery developed after an assault on a patient resulting in head injuries. Diagnostic imaging and endovascular treatment are described. Formation mechanisms of traumatic intracranial aneurysms are discussed and the literature is reviewed.

Etiologic study of stroke in 95 young adults

The aim of this prospective study was to determine the etiologic factors leading to stroke in a group of young adults. We studied 95 patients aged 50 years or under who were admitted with the diagnosis of stroke over a 2-year period. These patients underwent complete clinical and laboratory assessment for stroke. The etiology was established in 73 (76.8%) out of 95 cases. Arterial hypertension, embolism and atherosclerosis were found to be the most frequent causes in patients with ischemic stroke, whereas hypertension and aneurysm rupture were the most prevailing etiologies in patients with hemorrhagic stroke. Miscellaneous causes represented one fourth of all cases of the series. Coagulation abnormalities occurred in some patients, but in these cases there were also other well established causes. Paradoxical embolism was not observed. This study corroborates the importance of thorough diagnostic evaluation to establish an accurate diagnosis.

[Elaboration and evaluation of a fast detection system of mortality using Fourier analysis. Study of a value with maximal deviation]

BACKGROUND

To calculate all causes weekly baseline mortality and an alarm threshold using Fourier analysis. To analyse the largest outlier detected in our series.

METHODS

Madrid Undertaker database from October 1988 to September 1993, was used in the analysis. Orthogonal components were detected using Fourier analysis. Expected deaths and confidence limits were fitted using Serfling method. Alarm threshold was placed at a distance of 1.96 standard deviations above baseline.

RESULTS

orthogonal frequencies with significant amplitudes corresponding to periods 26, 52, 104 and 156 weeks were detected. The second was the fundamental and its multiples were harmonics. In the time domain, baseline mortality showed a winter peak, declined to a summer plateau and presented its lowest level at the end of August. 21 weeks exceeded the alarm threshold. Of these 17 were related to influenza epidemics. The largest outlier corresponded to a heat wave in July 1991.

CONCLUSIONS

A procedure similar to that proposed by R. E. Serfling (1963) to calculate baseline mortality, an alarm threshold and short term extrapolation using Madrid Undertaker database (C. Borrell, 1991) is presented. Madrid Undertaker database provide accurate and timely information about all causes mortality excess in Madrid.

Emergency embolectomy of middle cerebral artery occlusion due to microcoil migration: case report

We report a successful emergency embolectomy in a patient presenting a left middle cerebral artery occlusion by an embolizing microcoil that was being used to thrombose an aneurysm of the ophthalmic artery. In selected cases, emergency embolectomy can be considered as the treatment of distal embolization by the materials used in neuroendovascular procedures.

Cervical schwannoma presenting as a spinal subdural haematoma

We report a case of cervical spinal subdural haematoma as the presenting manifestation of a small intradural schwannoma. In patients without a bleeding diathesis and an apparently spontaneous spinal subdural haematoma, the possibility of an underlying tumour should always be considered.

A prospective study of stroke in young adults in Cantabria, Spain

BACKGROUND AND PURPOSE

The aim of this study was to determine the incidence, type, and prognosis of stroke in young adults in Cantabria, Spain.

METHODS

We investigated prospectively all patients aged 50 years or below who were admitted with the diagnosis of a stroke to the University Hospital "Marqués de Valdecilla" from April 1, 1986, to March 31, 1988. This is the main hospital of the region to which all patients with neurological problems are referred. These patients underwent a complete clinical and laboratory assessment for stroke and had 1-year mean follow-up.

RESULTS

The total series included 81 patients. The annual age-specific crude incidence rates of stroke were 17.3 and 10.4 per 100,000 for males and females, respectively. Twenty-four patients (30%) were diagnosed as having nonembolic cerebral infarction, 14 (17%) embolic cerebral infarction, 20 (25%) subarachnoid hemorrhage, 22 (27%) spontaneous cerebral hemorrhage, and one case (1%) cerebral venous thrombosis. Eighteen patients (22%) died within 30 days of the cerebrovascular event, and two others died during the follow-up period. Seventy-nine percent of the survivors recovered and were completely self-sufficient.

CONCLUSIONS

The incidence of stroke in the young found in Cantabria is comparable with that in previous studies. The initial hospital mortality was not negligible, but the prognosis among the survivors was favorable.

[The CHIVA cure of varices of the lower extremities. La Cure Conservatrice et Hemodynamique de l'Insuffisance Veineuse en Ambulatoire]

Presentation of the characteristics of this technique described by the French physician C. Franceschi, in 1988. Our Department began to apply this method on may 1991 and we are the first team in Spain to carry out and systematize this cure. Up to date, 85 patients have been treated with a residual vein percentage of 18%. Morbidity is low and slight. There is no mortality. This method is considered interesting as it does not require hospitalization, conserves the vein capital of the patient, and has low labour and health care costs.

Basichondrocranium anomalies in adult Chiari type I malformation: a morphometric study

The purpose of this study was to determine the frequency of anomalies of the basichondrocranium in a series of 42 patients with Chiari type I malformation compared with a control group of 46 subjects. Sixteen patients also had syringomyelia. Linear, angular and posterior fossa surface area measurements were taken on conventional lateral skull x-rays. Posterior fossa volume was estimated by CT scanning. In patients there was shortening of clivus length, Twining-opisthion distance and Chamberlain's line. Basal and Boogard angles were enlarged. The size of the posterior fossa was smaller in patients than in controls. Only 10 (23.8%) patients had no evidence of occipital dysplasia. When discriminant analysis was applied to the data, the most discriminative variables were posterior fossa area and clivus length which allowed accurate identification of 76% of patients as belonging to the patient group and 79% of controls as belonging to the control group. These findings prove that under-development of the basichondrocranium with a small size of the posterior fossa is an outstanding feature in adult Chiari type I malformation, and support the hypothesis that tonsillar ectopia is secondary to the disproportion between the posterior fossa and the cerebellum, which is forced to grow into the cervical spinal canal.

CT findings in spinocerebellar degeneration

Thirty-five CT scans were studied from patients with several forms of spinocerebellar degeneration. Atrophy was determined by objective measurements of the number and width of cerebellar sulci, transverse diameter and surface area of the fourth ventricle, brainstem ratio, cerebellopontine angle cistern, and Evans' index. Two-thirds of the patients with Friedreich's ataxia showed moderate cerebellar atrophy and an increase in the surface area of the fourth ventricle. Severe cerebellar atrophy and enlargement of the cerebellopontine angle cistern was seen in patients with olivopontocerebellar (OPC) atrophy and idiopathic cortical cerebellar atrophy. In the OPC atrophy group there was also prominent atrophy of the brainstem and an increase in the fourth ventricle parameters. Alcoholic cerebellar degeneration showed a specific pattern of cerebellar atrophy most prominent in the superior vermis, together with a slight increase in the fourth ventricle surface, a reduction in the size of the brainstem, and an enlargement of the cerebellopontine angle cistern. Supratentorial atrophy was present only in the OPC and alcoholic atrophy groups. In one patient with spastic ataxia, CT was normal but MR imaging revealed prominent atrophy of the spinal cord. These CT patterns appear to be distinctive enough to permit the diagnosis and classification of the various forms of spinocerebellar degeneration.

Late onset epileptic seizures. A retrospective study of 250 patients

A retrospective study of 250 patients with late-onset epilepsy was carried out. The ages ranged from 22 to 88. The seizures were partial in 104 patients and generalized in 146. The neurological examination was abnormal in 41 patients and normal in 209. The EEG studies and CT scan revealed abnormalities in 76.5% and 50.8% respectively. The most frequent CT scan findings were diffuse atrophy (19.2%), tumors (16.4%) and cerebral infarct (8.8%). The clinical parameters which best predicted the CT scan abnormalities were an abnormal neurological examination and simple partial seizures. In seven of the 45 patients with space-occupying lesions, the clinical examination and EEG were normal. The etiology of the convulsions was established in 201 patients, the most frequent cause being chronic alcoholism (62 cases), tumors (41 cases), postischemic vascular epilepsy (33 cases) and postraumatic epilepsy (28 cases). We conclude that a CT scan is essential in the assessment of patients with epileptic convulsions of late onset, even when the EEG and clinical examination are normal.

Cerebral arterial occlusion and intracranial venous thrombosis in a woman taking oral contraceptives

Occlusion of the middle cerebral artery and thrombosis of the superior sagittal sinus are reported in a 30-year-old woman taking oral contraceptives (OC). The coexistence of arterial and venous cerebral pathology as a complication of OC use has only been previously reported in one case. The pathogenesis of this rare association is briefly discussed.

Livedo reticularis and cerebrovascular lesions (Sneddon's syndrome). Clinical, radiological and pathological features in eight cases

Eight patients with diffuse livedo reticularis and cerebrovascular lesions (Sneddon's syndrome) are reported. The disorder was inherited by autosomal dominant transmission in 3 cases. Multiple occlusions in medium-sized arteries were demonstrated by cerebral and hand arteriograms. Digital artery biopsies showed intimal hyperplasia in 7 cases and recanalized thrombosis in one case. Our findings are compared with an extensive review of the literature. Differential diagnosis with other vascular disorders, especially cerebral thromboangiitis obliterans and the corticomeningeal angiomatosis of Divry and Van Bogaert is considered. We conclude that Sneddon's syndrome is a new genetic and progressive arteriopathy, occlusive and noninflammatory, involving medium-sized vessels. The pathogenesis has yet to be elucidated.

Occipital dysplasia and Chiari type I deformity in a family. Clinical and radiological study of three generations

Three generations of a family affected by a craniocervical malformation (CCM) were subjected to clinical and radiological studies. Occipital dysplasia (OD) and Chiari type I deformity (CD.I) were the main features, inheritance being autosomal-dominant. The malformation was variably expressed; it ranged from OD with basilar impression (BI) to OD without BI and from CD.I with OD to CD.I without obvious osseous malformation. Its pathogenesis, and that of other related familial disorders (Klippel-Feil syndrome and syringomyelia), is discussed, the conclusion being drawn that all were elements of one genetic disorder which finds expression in a very variable sequence. The value of high-resolution CT in the detection of asymptomatic carriers is emphasized.

Giant aneurysm of the intracavernous carotid artery and bilateral carotid fibromuscular dysplasia

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Occipitoatlantal instability and vertebrobasilar ischemia: case report

A 37-year-old woman had occipitoatlantal instability due to hypoplasia of the occipital condyles. Neck pain and transient ischemic attacks in the vertebrobasilar territory occurred with extension of the neck, which also caused convergence spasm. Angiography demonstrated that these manifestations were due to compression of the vertebral arteries during neck extension. Immobilization of the neck in a Minerva cast resulted in complete relief of symptoms.

Angiographic changes in a case of herpes simplex encephalitis

A case of herpes encephalitis predominating in the right temporal lobe with unusual angiographic changes is reported. Carotid angiography revealed a right temporal mass with vascular blush and early venous filling through irregular veins. Early venous filling and vascular blush have been known for a long time with cerebral inflammatory disease, but venous drainage through irregular veins is unusual.