Subdural Haematoma in Patients With Spontaneous Intracranial Hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.

Differences in brain metabolism associated with agitation and depression in Alzheimer's disease

OBJECTIVE

Agitation and depression are among the commonest behavioural and psychological symptoms exhibited by Alzheimer's disease patients. However, their pathophysiology remains unclear. We therefore investigated the relationship between the brain metabolism in the posterior cingulate gyrus and the dorsolateral prefrontal cortex, and agitation and depression in patients diagnosed with Alzheimer's disease.

METHODS

We recruited 26 patients (14 women and 12 men) with a mean age of 75 years and probable Alzheimer's disease. All patients completed the Mini-Mental State Examination (MMSE), the Geriatric Depression Scale-Short Form (GDS) assessment, and the Cohen-Mansfield Agitation Inventory (CMAI) in order to evaluate cognition, depression, and agitation, respectively. All subjects underwent magnetic resonance imaging and (1)H-magnetic resonance spectroscopy of the brain. The ratios of N-acetylaspartate (NAA), choline (Cho), and myo-inositol (mI) to creatine (Cr) in the posterior cingulate gyrus and the dorsolateral prefrontal cortex were measured and compared with neuropsychological test results.

RESULTS

The MMSE scores correlated positively with the NAA/Cr ratio in the left posterior cingulate gyrus (r = 0.56; p = 0.001). The CMAI scores correlated negatively with the NAA/Cr ratio in the left posterior cingulate gyrus (r = -0.46; p = 0.02). The GDS scores correlated positively with the Cho/Cr ratio in the left dorsolateral prefrontal cortex (r = 0.59; p = 0.01), and mI/Cr in both left (r = 0.47; p = 0.03) and right (r = 0.47; p = 0.03) cingulate gyri.

CONCLUSIONS

Agitation and depression levels correlated with different neurochemical metabolites in specific brain areas. We conclude that various neuropsychiatric symptoms might have separate pathophysiologies.

Contribution of intracranial vertebral artery asymmetry to vestibular neuropathy

OBJECTIVES

To test the hypothesis that vertebral artery hypoplasia (VAH) may affect the lateralisation of vestibular neuropathy (VN), probably through haemodynamic effect on the vestibular labyrinth.

METHODS

69 patients with unilateral VN were examined with a magnetic resonance angiographic (MRA) and caloric test. 50 healthy subjects served as controls. The diagnosis of intracranial VAH was based on MRA if <0.22 cm in VA diameter and a diameter asymmetry index >40%. The authors then correlated the canal paretic side with the VAH side.

RESULTS

MRA study revealed 29 VAH (right/left: 23/6) in VN subjects and six VAH in controls (right/left: 5/1). The RR of VAH in VN subjects compared with controls was elevated (RR=2.2; 95% CI 1.8 to 2.8). There was a high accordance rate between the side of VAH and VN. Among 29 patients with unilateral VAH, 65.5% (N=19) had an ipsilateral VN, in which left VAH showed a higher accordance rate (83.3%) than the right side (60.9%). VN subjects with vascular risk factors also had a higher VAH accordance rate (81%) than those without (25%).

CONCLUSIONS

VAH may serve as a regional haemodynamic negative contributor and impede blood supply to the ipsilateral vestibular labyrinth, contributing to the development of VN, which could be enhanced by atherosclerotic risk factors and the left-sided location.

Prediction of Alzheimer's disease in mild cognitive impairment: a prospective study in Taiwan

The relationship between apolipoprotein E (ApoE) and clinical manifestations of mild cognitive impairment (MCI) has not been investigated in non-Caucasian populations. This prospective study was conducted in an ethnic Chinese population to evaluate the correlations of ApoE genotype, cognitive performance, medial temporal structure volumes, and clinical outcome in amnestic MCI. Twenty normal elders, 58 MCI, and 20 mild Alzheimer's disease (AD) patients received neuropsychological, MRI, and ApoE genotype assessments at baseline. Patients with MCI had intermediate cognitive performance and hippocampal volumes between those in normal and AD groups. In each diagnostic group, epsilon4 carriers (E4+) consistently had smaller hippocampal volume than non-carriers (E4-) did. Nineteen MCI subjects (32.7%) converted to AD during the 3-year study period. Compared with MCI non-converters and E4- MCI converters, E4+ MCI converters had the smallest hippocampal volume. However, epsilon4 was not a predictor for AD. Both cognitive performance and hippocampal volume were predictive for progression to AD. However, stepwise Cox regression model integrating both neuropsychological and radiological variables showed that global cognitive performance was the only significant predictor for AD. A poor global cognitive score may be more crucial than a small hippocampal volume in the prediction of AD.

Carotid blowout treated by direct percutaneous puncture of internal carotid artery with temporary balloon occlusion

SUMMARY

Direct percutaneous puncture of a cervical carotid pseudoaneurysm for coil placement or acrylic embolization is described for the endovascular management of acute carotid blowout. However, direct puncture of the internal carotid artery (ICA) for the endovascular management of carotid blowout has not been described. We report a difficult case of acute carotid blowout syndrome in a patient who had radiation- induced occlusion of the right common carotid artery with vasculopathy and pseudoaneurysm in the right cervical ICA. Collaterals from the branches of the controlateral external carotid artery (ECA) anastomosed with branches of right ECA supplied the vasculopathy. We performed direct percutaneous puncture of the bulb of the right ICA using a spinal needle and placed fiber coils to occlude antegrade flow of the artery. During the injection of a mixture of N-butyl cyanoacrylate and lipiodol oil for embolization of the remaining carotid bulb, we transiently inflated an occlusion balloon in the controlateral common carotid artery to further arrest antegrade flow in the ICA. The vasculopathy and pseudoaneurysm of the right cervical ICA were successfully embolized, with preservation of the distal branches of the right ICA.

Posterior cranial fossa crowdedness is related to age and sex: an magnetic resonance volumetric study

PURPOSE

To measure 3-dimensional (3D) posterior cranial fossa (PCF) crowdedness and to evaluate the effect of age, sex, and body height on PCF.

MATERIAL AND METHODS

Fifty-two healthy volunteers (24 M and 28 F; mean age 55.4 +/- 17.2 years; range 24-82 years) were recruited. Using a semi-automated magnetic resonance technique, we calculated a PCF crowdedness index (CI) as the ratio of hindbrain (HB) volume to PCF volume x 100% and correlated this index with age, sex, body height, and other crowdedness parameters.

RESULTS

The mean PCF CI was 93.7 +/- 2.7%. Women had a more crowded PCF than men (95.0+1.7% versus 92.1 +/- 2.7%; P<0.001). PCF CI declined with age for both men (r = -0.61; P=0.002) and women (r = -0.68; P<0.001). The association with age--but not HB volume was maintained after we controlled for sex and body height. On multiple regression, both age and sex accounted for 57.5% of the PCF CI variance.

CONCLUSION

Our study shows that PCF CI is associated with age and sex, and can therefore be used as a surrogate to assess hindbrain atrophy in a cross-sectional sample. Moreover, sex- and age-specific normal ranges may be needed to evaluate the PCF CI in clinical practice.

Neuroradiological findings in atypical teratoid/rhabdoid tumor of the central nervous system

PURPOSE

To evaluate the computed tomography (CT) and magnetic resonance imaging (MRI) findings of atypical teratoid tumor/rhabdoid tumor (AT/RT) of the central nervous system (CNS).

MATERIAL AND METHODS

Twenty cases of CNS AT/RT have been found over the past 23 years in our hospital; these involving 11 boys and 9 girls whose mean age at diagnosis was 5.5 years. Their clinical data, the CT, and MRI findings were reviewed retrospectively.

RESULTS

AT/RT was located in the cerebellum in 15 cases. Four cases arose from the supratentorial region, while only one occurred primarily in the lumbar spinal cord. Almost all cases revealed heterogeneous intensity and heterogeneous enhancement. Peripheral cystic components were common. Survival time ranged from 2 months to 3 years, with a mean survival of 11.6 months.

CONCLUSION

Most cases of AT/RT are located in the cerebellum. The radiologic manifestations are non-specific. The diagnosis mainly depends on the pathologic findings. However, AT/RT should still remain in the differential diagnosis of brain tumors in young children, especially those located in the cerebellar hemisphere and with eccentric cysts.

Sequential MRI studies of a patient with complex partial status--a case report

Complex partial status (CPS), the status epilepticus of complex partial seizure, is rarely seen in clinical practice. The clinical presentations of CPS are characterized by confusion, slowness in response, together with stereotypic or complex automatisms and occasional secondary generalization. The electroencephalographic findings of CPS reveal characteristic focal epileptiform activities of mesial temporal region. Magnetic resonance image (MRI) is the imaging method of choice for studying epilepsy, particularly when focus is in the temporal lobe. We report a 49-year-old female with diagnosis of viral encephalitis and clinical presentation of CPS. We present the sequential brain MRI findings at acute, subacute and chronic stages of this patient.

Magnetic resonance imaging appearance of intradural spinal lipoma

Intradural spinal lipoma not associated with spinal dysraphism is a rare tumor often presenting with nonspecific symptoms and indolent clinical course. Its intradural location and fat component is the key for proper preoperative diagnosis, which could hardly be made by traditional imaging studies including plain film and myelography. Both CT and MRI can reveal the fat component of the tumor, but MRI is superior to CT in demonstrating its relationship with adjacent normal nerve tissue. We report a 32-year-old man who had back pain for years and the symptom progressed rapidly in recent two months. MRI revealed an intradural tumor at T12 level with high signal intensity on both T1- and T2-weighted images. The signal intensity dropped dramatically with fat saturation technique, which confirmed fat as its main component. The patient received surgery and the tumor was proved to be an intraspinal lipoma.

Sequential MR studies of a patient with white matter disease presenting psychotic symptoms: ADEM versus single-episode MS

Acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS) are both demyelinating white matter disorders. It is difficult to differentiate ADEM from single episode MS because of the similar clinical presentation, cerebral spinal fluid (CSF) analysis, histological finding and magnetic resonance image (MRI) appearance. We report an ADEM case with unusual clinical presentations of predominant psychiatric symptoms, and relatively long disease course. Initially, we were not able to distinguish it from single episode MS. By means of sequential MR images followed up 2 years and spectroscopy studies, and the dramatic clinical improvement after corticosteroid therapy, ADEM was diagnosed as the disease entity of this patient. In this case report we will present the MR findings of this patient and discuss the differentiation between the ADEM and MS.

Image evaluation of suprazygomatic masticator space lesions

In order to understand lesions involving the suprazygomatic masticator space (SZMS) demonstrated on computered tomography (CT) or magnetic resonance (MR) images, we collected 45 cases of lesions in SZMS. There were hematomas in 26 cases, tumors in 16 cases, and abscesses in 3 cases. The location of these lesions in compartments of the SZMS and adjacent structures was analyzed. Most commonly hematoma was found in the deep loose connective tissue (80.8%), followed by the superficial dense connective tissue (61.5%). Only 2 SZMS hematoma involved the superficial fat pad. Five patients had air accumulation in the SZMS, and all were in the deep fat pad and with maxillary sinus fracture. Of the sixteen cases which were tumors, 12 were extended from adjacent structures, and four were primary tumor. In cases of tumor, compartments of SZMS involved most frequently were temporal muscles (15 of 16 cases), followed by deep fat pad (8 of 16 cases). The connective tissue layer of SZMS is a communication pathway for superficial spread of infection, hematoma, or tumor invasion to or from the scalp and face. Compartments of deep fat pad and temporal muscle are also pathways for the spread of disease to or from the face, intracranium and orbit. The primary tumors in infratemporal fossa and SZMS are rare. Malignant tumors in SZMS usually come from surrounding spaces.

Repetitive phenomena in dementia

OBJECTIVE

Both repetitive talk and behaviors (repetitive phenomena) are common in demented patients and are bothersome to their caregivers and families. The purpose of this preliminary report was to explore these repetitive phenomena in demented patients admitted to a geropsychiatric ward.

METHOD

The sample population consisted of 141 demented patients. Patients' caregivers were asked if patients had presented a repetitive fixed pattern of physical action or talk since the onset of dementia.

RESULTS

Of the 141 demented patients included in the study, seventy-nine had repetitive phenomena. Patients with these phenomena had various presentations and developed them in the early stage of dementia.

CONCLUSIONS

Repetitive phenomena are widespread in dementia, especially for older patients, and may be an early sign of dementia. The characteristics of repetitive phenomena and some likely underlying mechanisms are discussed.

Epileptic seizures in a patient by immersing his right hand into hot water

We report on a 22-year-old assistant cook, presenting with seizures evoked by immersing his right hand into hot water of 40-46 degrees C. His seizure pattern consisted of either simple partial seizures of a tingling sensation arising in the right hand and marching to the right shoulder or a similar attack evolving to a complex partial seizure. Video-EEG monitoring recorded habitual seizures originating from the left centro-temporo-parietal region, compatible with lesions seen on brain magnetic resonance imaging. He responded well to antiepileptic drug treatment and wearing gloves while working in the kitchen. In this patient, hot water of 40-46 degrees C could maximally stimulate skin warm thermoreceptors in the right hand whereby afferent impulses subsequently activated the epileptogenic focus, adjacent to or in the sensory cortex, and elicited seizures.

Fat in the cerebral falx

BACKGROUND

Fat within the cerebral falx is commonly encountered in our daily practice but has never been characterized and reported. The purpose of this study was to determine the incidence of fat within the cerebral falx and to identify its clinical features.

METHODS

The cerebral falx was prospectively imaged in 1,570 consecutive brain computed tomographic scans and its features characterized. Cerebral magnetic resonance imaging was done in some patients.

RESULTS

Of the 1,570 cases studied, 115 revealed a small amount of fat in the cerebral falx. This fat had a purely negative Hounsfield value. It produced a high signal on both T1- and T2-weighted magnetic resonance images. There was no calcified component. The fat was seen most commonly in aged patients. No related symptoms were noted.

CONCLUSIONS

Among the patients studied, fat in the cerebral falx had an incidence of 7.3%. It is an incidental finding in adults and requires no further evaluation or treatment.

Computed tomography and magnetic resonance imaging characteristics of giant pituitary adenomas

PURPOSE

The purpose of this study was to characterize the computed tomography (CT) and magnetic resonance (MR) imaging features of giant pituitary adenoma (GPA) and to demonstrate the pathways of the spread of GPA.

METHODS

CT and/or MR imaging scans of 356 patients evaluated preoperatively for single pituitary tumor were reviewed. Fourteen tumors (4%) fulfilled the radiologic criteria for GPA. There were 10 male and four female patients, ranging in age from 22 to 71 years (mean, 52 yr). We retrospectively reviewed the CT and MR imaging scans of these patients to characterize tumor appearances and identify the pathways of tumor extension.

RESULTS

Thirteen tumors (93%) extended upward to the suprasellar cistern, and/or hypothalamus and third ventricle. Infrasellar extension through the sellar floor and sphenoid sinus to the skull base, or to the ethmoid sinus or the nasopharynx, was identified in seven patients (50%). Eight patients (57%) had lateral invasion to the cavernous sinus. Temporal and frontal extension was apparent in seven patients (50%) and six patients (43%), respectively. Five patients (36%) had posterior subtentorial extension to the posterior fossa. Histologically, only two GPAs showed invasive features. There was no correlation among histologic features, pituitary hormone concentrations, and evidence of tumor aggressiveness on CT and MRI scans.

CONCLUSIONS

GPA has the potential for widespread, multi-directional extension. Our results indicate that any type of pituitary adenoma, regardless of its endocrinologic activity, may invade surrounding structures. Suprasellar invasion is the most common pathway of tumor spread, followed by infrasellar, lateral, anterior, and posterior routes.

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.

Salvage surgery for recurrent nasopharyngeal carcinoma

OBJECTIVE

To evaluate the efficacy of salvage surgery in the treatment of recurrent nasopharyngeal carcinoma (NPC) at the primary site.

STUDY DESIGN

A retrospective investigation of the outcome of salvage surgery for 28 patients with recurrent NPC after definite radiation therapy.

METHODS

The nasopharynx was approached anteroposteriorly by the transmaxillary approach (maxillary swing, maxillectomy) or inferior approach (midline mandibulotomy or median labiomandibular glossotomy), or laterally by modified facial translocation or transpterygoid approach; intentional ligation of the internal carotid artery was performed after establishment of extracranial-intracranial (EC-IC) bypass in one patient; postoperative irradiation was given to the patients with positive pathological margins.

RESULTS

Nine patients lived without disease for 20 to 93 months (mean interval, 52 mo) after surgery; among them, eight patients had T1 tumors that were resected totally by surgery via anteroposterior approaches and the other patient had postoperative irradiation to control the disease. Seven patients had local recurrence 8 to 21 months after treatment. Four patients developed distant metastases, including one patient with a T2b tumor that was totally resected through modified facial translocation approach with ligation of internal carotid artery. Eight patients died of other causes; internal carotid artery blowout was the cause of death in four of these eight patients.

CONCLUSIONS

In most cases of recurrence, T1 nasopharyngeal tumors can be resected totally by anteroposterior approaches; for T2 or larger tumors, postoperative irradiation is usually necessary. Otherwise, facial translocation offers a better chance to completely resect the tumors. Internal carotid artery is better ligated if patients have received greater than 70 Gy irradiation or if the artery must be exposed during the surgery. We suggest that EC-IC bypass be used to avoid the possible complications (or cerebral ischemic stroke) caused by ligation of internal carotid artery. The transmaxillary approach is favored in the management of nasopharyngeal tumor recurrence with nasal cavity extension, and midline mandibulotomy is more suitable for resection of posterior margin of nasopharyngeal tumor recurrence. Facial translocation offers the widest operative field and is the most versatile approach for radical resection of nasopharyngeal tumor recurrence, but the surgeon should be skilled in the management of the facial nerves to reduce morbidity.

Aberrant cervical carotid artery

Aberrant cervical carotid artery is an uncommon anomaly. Because this anomaly can lie in close proximity to the midline of the posterior part of the pharynx, it poses a significant risk during both major pharyngeal tumor resection and less extensive procedures such as tonsillectomy, adenoidectomy and palatopharyngoplasty. Five cases of aberrant cervical carotid artery were encountered and diagnosed using computerized tomography. In all five cases, the anomalous finding did not correlate with the presenting symptoms. Computerized tomographic images of these cases are provided. A review of the literature and the embryology of the aberrant carotid artery are presented. Awareness of the anomaly by radiologists and surgeons is essential to avoid accidental injury to the vessel during surgery.

Cavernous sinus gas

Gas within the cavernous sinus is an unusual finding. We report three patients who demonstrated gas in the cavernous sinus on computerized tomography (CT). The clinical information of these patients was reviewed for the possible source of the gas and the symptoms induced by the gas. Cavernous sinus gas was seen in two patients with sphenoid sinus fracture and in one patient after intravenous fluid infusion. None of the patients had symptoms referable to the cavernous sinus gas, but one patient had a grave prognosis due to trauma. Identification of cavernous sinus gas on CT and correlation with the clinical information is mandatory for further management.

Endovascular embolization of intractable epistaxis

BACKGROUND

We undertook this study to define the role of angiography and endovascular embolization in the treatment of patients with intractable epistaxis.

METHODS

A series of 19 patients with massive intractable epistaxis, all treated with endovascular embolization were reviewed. There were 15 males and four females ranging in age from 18 to 70 years, with a mean age of 38 years. The predisposing factors of intractable epistaxis were head and neck tumors (n = 11), idiopathic symptoms (n = 3), surgical complications (n = 2), arteriovenous malformation of the face (n = 1), thrombocytopenia (n = 1) and trauma (n = 1). Polyvinyl alcohol (PVA) particles and gelfoam plugs were used as embolic agents in 11 patients for devascularization; detachable balloons with N-butyl-2-cyanoacrylate (NBCA) were used in four patients for vascular occlusion; NBCA and/or coils were used in four patients in the carotid and subclavian arteries for obliteration of pseudoaneurysms.

RESULTS

Complete cessation of epistaxis was achieved in all 19 patients immediately after embolization. Seven patients had also undergone surgical tumor removal at two to five days after embolization. Two patients experienced mild to moderate facial pain on the first day after the procedure, but the symptoms later subsided. No significant complication or recurrence was observed in 18 patients. One patient with advanced hypopharyngeal carcinoma died two weeks after embolization due to another episode of massive epistaxis. Clinical follow-up for these patients was 15 days to eight years, with a mean of 41 months.

CONCLUSIONS

Therapeutic endovascular embolization of intractable epistaxis is both efficient and safe. It should be considered as the primary treatment modality in intractable epistaxis.

Imaging of invasiveness of pituitary adenomas

The purpose of our study was to examine the tumor size, imaging invasiveness of the pituitary macroadenomas (PMA) and to evaluate the directions of PMA spread. One hundred and thirty-five patients with PMA were examined with MRI and/or CT for pre-operative evaluation. We retrospectively reviewed the CT and MRI to identify tumor size, extension and to evaluate the directions of tumor spread. One hundred and seventeen patients (87%) had suprasellar extension with compression of optic apparatuses, twelve patients (9%) had extension of tumor upward to hypothalamus and third ventricle. Infrasellar extension via the floor of the sella and sphenoid sinus was found in thirty-eight patients (28%), and further downward extension to ethmoid sinus, nasopharynx and/or skull base was depicted in five patients (4%). Twenty-two patients (16%) had lateral invasion to the cavernous sinus and associated cranial nerves. Temporal and frontal extensions were depicted in seven patients (5%) and six patients (4%), respectively. Five patients (4%) had posterior subtentorial extension to posterior fossa. Histologically, only two patients showed microscopic invasive features. There was no correlation between histologic features and imaging invasiveness. The PMA had the potential of multi-directional extension. This experience indicated any type of pituitary adenoma could invade surrounding structures. Suprasellar invasion was the most common direction of pituitary adenoma spread, followed by infrasellar, lateral, anterior and posterior routes.

Giant cell reparative granuloma: a case report

Giant cell reparative granuloma (GCRG) is an infrequent benign lesion with undetermined etiopathogenesis affecting the maxillary and mandibular bone and, rarely, the skull. It is also extremely rare in the sphenoid bone. GCRG is usually diagnosed by histologic examination of bone lesions. We report a case of GCRG originating from the sphenoid bone. Computerized tomography revealed an expansile lesion with thinning or destruction of the cortical bone. The lesion itself was slightly hyperdense with good but inhomogeneous contrast enhancement. Reported magnetic resonance image findings showed hyperintensity on both T1-weighted and T2-weighted images and variable contrast enhancement. Plain skull radiographs usually reveal a lytic lesion within the bone.

Magnetic resonance imaging of unilateral olivary hypertrophy due to pontine tegmental hemorrhage: a case report

Olivary hypertrophy (OH) is not a primary lesion but, rather, develops as a lesion of the Guillain-Morraret triangle, which is composed of the contralateral dentate nucleus, the ipsilateral red nucleus and the ipsilateral inferior olivary nucleus. OH is usually accompanied by palatal myoclonus or other involuntary movements such as extremity myorhythmia. One case of unilateral OH following ipsilateral pontine tegmental hemorrhage is presented. Magnetic resonance imaging (MRI) showed high signal intensity in the inferior olivary nuclei on T2- and proton-density-weighted images. Enlargement of the inferior olivary nuclei was also noted. MRI may currently be the only procedure capable of confirming the diagnosis.

Intracranial pathology: comparison of intraoperative ultrasonography with computerized tomography and magnetic resonance imaging

BACKGROUND

High-resolution, real time, intraoperative ultrasonography (IOUS) has been used in a number of cases in our neurosurgical department to identify, localize and characterize intracranial abnormalities. We compare the images of IOUS with those of computerized tomography (CT) and magnetic resonance imaging (MRI) in order to enhance our experience and confidence.

METHODS

IOUS images were compared with preoperative CT scans and/or MRIs in 30 intracranial masses. Tumor size and margin, echogenicity and edema were the features compared.

RESULTS

The images of IOUS, CT and MRI correlated closely except for images of primary gliomas. IOUS was more effective than CT and MRI in delineating the extent of a glioma, determining whether a lesion was cystic, with or without septation, or solid and in guiding surgical procedures. The contrast enhancement available with CT and MRI could not be demonstrated with IOUS.

CONCLUSIONS

IOUS provides exquisite detail of intracranial pathology as well as, or even better than, CT and MRI. Its application should be emphasized to minimize damage of normal brain tissue and increase the completeness of tumor resection.

Persecutory delusions in dementia

BACKGROUND

Persecutory delusions are common in dementia. This study was undertaken to investigate the prevalence, associated factors, and characteristics of persecutory delusions in demented patients.

METHOD

The sample population included 167 demented patients (DSM-III-R criteria) admitted to a geropsychiatric ward. Patients were assessed for the occurrence of any persecutory delusions since the onset of dementia. The content of persecutory delusions, the patients' response to the delusions, and any concomitant psychiatric symptoms were also explored.

RESULTS

Of the 167 demented patients, 45 (26.9%) showed symptoms of persecutory delusions. Patients with persecutory delusions had a higher prevalence of other delusions, hallucinations, and physically aggressive behaviors. The deluded patients often thought that their caregivers were their persecutors and had a wide range of responses to their delusions. After they were hospitalized, many of these patients attacked medical staff and were uncooperative with treatment.

CONCLUSION

Persecutory delusions are common in dementia of various types. Deluded patients often have vigorous responses to their delusions including physically aggressive behaviors and suicide attempts. Careful evaluation is needed to assess the potential for violent and suicidal behaviors in these patients. Medical staff should be alert to clinical strategies for handling the treatment of such patients when they become violent or uncooperative.

Inappropriate sexual behaviors in dementia: a preliminary report

We investigated types of inappropriate sexual behavior (ISB) and patient characteristics in geriatric patients with dementia. The study group consisted of 133 consecutive geropsychiatric demented patients admitted to our ward. All patients underwent standardized diagnostic procedures for dementia, and ISB was assessed by a questionnaire completed by patients' caregivers and records during hospitalization. Patients were then subdivided on the basis of the presence or absence of ISB. Of the 133 demented patients, 20 (15.0%) were reported to demonstrate ISB at home or during hospitalization. Patients with ISB had various types of dementia. There were no significant differences in patients with and without ISB in regard to age, age of onset, gender, educational level, or Mini-Mental State Examination scores. ISB is not unusual in dementia patients and can be found in different types of dementia. Medical care providers need to be trained to discuss sexual issues with caregivers and offer ideas and training to help cope with patients with ISB.

Arachnoid granulations--computerized tomography and magnetic resonance imaging features: a case report

A 71-year-old woman had arachnoid granulations found in the straight and transverse sinuses on computerized tomography (CT) and magnetic resonance imaging (MRI). The arachnoid granulations appeared as low-density masses on CT. They gave low signals on T1-weighted MR images and high signals on T2-weighted images. Arachnoid granulations are usually of no clinical significance. They have characteristic CT and MRI manifestations and should not be mistaken for sinus thrombosis or intrasinus tumors.

Hoarding behavior in dementia. A preliminary report

Hoarding behavior has been reported in several mental disorders and is occasionally reported by the caregivers of dementia patients. Such behavior may have adverse effects on the patients and increase the burden of the caregivers. This study was conducted to investigate the prevalence of hoarding behavior in patients with dementia and identify the characteristics and psychiatric symptoms associated with it. The sample was 133 dementia patients admitted to a geropsychiatric ward. Of the 133 dementia patients, 30 (22.6%) showed hoarding. Hoarding was found in various types of dementia. Patients with hoarding had a higher prevalence of repetitive behaviors, hyperphagia, and pilfering. Results suggested that hoarding behavior is a common symptom in dementia patients and a complex phenomenon. Better understanding of the underlying pathogenesis may highlight specific pharmacological or behavioral methods for treatment of the behavior.

Orbital invasion in nasopharyngeal carcinoma: evaluation with computed tomography and magnetic resonance imaging

BACKGROUND

Ocular symptoms and tumor cranial nerve involvement are commonly observed in patients with nasopharyngeal carcinoma (NPC). These are primarily due to tumor invasion of the cavernous sinus and/or skull base, as direct tumor invasion of the orbit is very rare. This study was designed to assess computed tomography (CT) and magnetic resonance imaging (MRI) in documenting orbital invasion caused by NPC, with a special emphasis on the route of orbital extension.

METHODS

A total of 562 patients with histopathologically prove NPC were examined using CT and/or MRI for tumor staging or post-treatment follow-up. We retrospectively reviewed CT and MRI findings to identify tumor invasion to orbital cavities and to evaluate the pathway of tumor spread.

RESULTS

Eighteen patients had tumor extension into the orbital cavities. Seventeen patients had ocular complaints. Fourteen of 18 showed unilateral orbital involvement and four patients showed bilateral orbital involvement. The route from the pterygopalatine fossa and inferior orbital fissure into the orbital cavities was the most common pathway of NPC invasion (n = 13), followed by ethmoid sinus and/or sphenoid sinus into the orbits (n = 4). In one patient, the route of orbital invasion was difficult to determine due to massive tumor extension.

CONCLUSION

Direct orbital invasion is rare in NPC. The pterygopalatine fossa and inferior orbital fissure are the most common routes of invasion, followed by invasion via the ethmoid and/or sphenoid sinuses. Coronal sections best show these findings on CT or MRI. Our study also shows that either CT or MRI provide essential information in documenting orbital invasion and determining the pathway of tumor spread.

Verifying complete obliteration of carotid artery-cavernous sinus fistula: role of color Doppler ultrasonography

The purpose of this study was to evaluate the role of color Doppler ultrasonography in verifying obliteration of carotid artery-cavernous sinus fistula before and after therapeutic embolization or gamma knife radiosurgery. Before treatment, carotid artery-cavernous sinus fistula showed the following data on color Doppler ultrasonography: (1) increased blood flow in the common carotid artery (220 to 1264 ml/min with mean+/-SD of 728+/-378 ml/min); internal carotid artery (435 to 1097 ml/min with mean+/-SD of 834+/-216 ml/min) in fistulas of the direct type; and external carotid artery (85 to 257 ml/min with mean+/-SD of 170+/-75 ml/min) in fistulas of the indirect type in comparison to the contralateral side; (2) reverse pulsatile flow or spiculated wave form with turbulent flow in the engorged superior ophthalmic vein on the lesion side in all patients. All of the above abnormal hemodynamic changes became normal in six patients immediately after first embolization, in two patients with balloon embolization combined with subsequent direct embolization by direct puncture through the superior orbital fissure or internal carotid artery embolization, and in five patients after gamma knife radiosurgery at 4, 4, 8, 9, and 9 months, respectively. Color Doppler ultrasonography might be a good modality in long-term follow-up of carotid artery-cavernous sinus fistula after gamma knife radiosurgery and embolization.

Endovascular embolization of arteriovenous fistulas of the external carotid artery

BACKGROUND

External carotid arteriovenous fistulas (AVFs) are rare and most hospitals have limited experience with their management. This study was designed to evaluate the effectiveness and safety of endovascular embolization of AVFs of the external carotid artery under angiographic control.

METHODS

A series of 13 patients with AVFs involving the branches of the external carotid artery, all treated with endovascular embolization, were reviewed. There were 10 males and three females ranging in age from nine to 46 years, with a mean of 27 years. The most frequent presenting symptoms were pulsatile tinnitus, followed by bruit and/or thrill, ocular problems, headache and a pulsatile mass in the neck. The middle meningeal artery was most often involved, followed by the internal maxillary artery and the occipital artery. The AVFs were caused by trauma in 10 patients and occurred spontaneously in three. N-butyl-2-cyanoacrylate was used to embolize the fistula in 11 patients and a detachable balloon was used in two.

RESULTS

All the patients were cured and no significant complications were observed. No recurrence was noted after a clinical follow-up of three months to seven years (mean, 37 months).

CONCLUSIONS

Endovascular embolization proved to be a safe and effective procedure. It should be the treatment of choice for repair of external carotid AVFs.

Proton magnetic resonance spectroscopy in deep cerebral venous thrombosis

A 63-year-old man developed a severe left frontal headache followed by an acute change of mentality 6 days later. Magnetic resonance imaging revealed bilateral thalamic ischemia. Angiography confirmed the occlusion of deep cerebral veins. Proton magnetic resonance spectroscopy (1H-MRS) of the thalami showed normal N-acetylaspartate (NAA) peak and the presence of lactate peak, indicating a relatively preserved neuronal viability. The patient improved during the follow-up period, and returned to work 45 days after the onset of the disease. With 1H-MRS, prognosis following venous infarctions may be feasible.

Intracranial ganglioglioma: CT and MRI findings

Thirteen cases of pathologically proved intracranial gangliogliomas were reviewed in order to define the characteristic computed tomography (CT) and magnetic resonance image (MRI)-features. All patients were evaluated with CT and four of them were studied by MRI. Six tumors were cystic dominant mixed masses with remarkable focal contrast enhancement (6/13, 46%); and seven were solid in nature with variable contrast enhancement (7/13, 54%). Nine of them contained calcification (9/13, 69%). The temporal lobe was affected in six patients (6/13, 46%); the posterior fossa in four patients; the frontal lobe in two; the remaining huge one in the frontal, temporal and basal ganglion. On MRI, the findings were similar to those of the CT. Gangliogliomas do not have a characteristic CT and MRI features. They may appear as pure cystlike tumors, cystic dominant mixed tumors with remarkable focal contrast enhancement, solid tumors with variable contrast enhancement or diffuse involving the brain parenchyma and/or subarachnoid spaces. However, radiologists should include ganglioglioma in the differential diagnosis when we find patient has a long-standing process as well as a calcified tumor in the temporal lobe with following characteristic; cystic dominant mixed tumor with remarkable focal contrast enhancement, or a solid mass without hemorrhage or significant surrounding edema.

Chorea-ballismus with nonketotic hyperglycemia in primary diabetes mellitus

PURPOSE

To describe the neuroimaging (Ct, MR, and single-photon emission CT [SPECT]) findings in a series of patients with chorea-ballismus associated with nonketotic hyperglycemia in primary diabetes mellitus and to correlate the imaging findings with the clinical presentation.

METHODS

The neuroimaging and clinical data from 10 patients with chorea-ballismus associated with nonketotic hyperglycemia in primary diabetes mellitus were evaluated. Family and drug histories, as well as other causes of chorea, were excluded. All 10 patients had CT, 5 also had MR imaging, and 3 had SPECT examinations. Three had follow-up CT and MR imaging studies, and MR findings were correlated with CT findings in 5 cases. Two experienced neuroradiologists, aware of the diagnosis but blinded to the clinical status of the patients, evaluated all images and reached a consensus as to the final interpretation.

RESULTS

CT studies in 9 of 10 patients showed a hyperdense putamen and/or caudate nucleus; in 1, the CT findings were normal. T1-weighted MR images in all 5 patients who had MR imaging (including the patient with a normal CT study) showed hyperintense lesions without significant T2 signal alternation at the basal ganglia. In all 3 of the patients who had SPECT studies of the brain, the scans revealed hypoperfusion at corresponding areas. All 3 follow-up studies depicted resolution of the lesions in the abnormal basal ganglia. Increased hypointensity on T2-weighted and gradient-echo T2*-weighted images was also observed in the sequential MR images. In all patients, the initial side of involvement correlated well with the neuroimaging findings. The chorea resolved within 2 days after treatment of the hyperglycemia in 9 patients.

CONCLUSION

In patients with chorea-ballismus associated with nonketotic hyperglycemia in primary diabetes mellitus, CT and T1-weighted MR images show unilateral or bilateral lesions of the putamen and/or caudate. SPECT scans show hypoperfusion. These findings may be related to petechial hemorrhage and/or myelin destruction. Early recognition of these imaging characteristics may facilitate diagnosis of primary diabetes mellitus with hyperglycemia and prompt appropriate therapy.

MRI of papillary meningiomas in children

We report two cases of papillary meningioma in children. The MRI appearance of this special type of meningioma is described for the first time. Both lesions were dura based and associated with cystic components. We review the literature pertaining to this type of meningioma and discuss the differential diagnosis of the MRI appearance. Because this is a malignant type of meningioma, early diagnosis and surgical intervention are important in the management of patients.

Cerebral phaeohyphomycosis complicated with brain abscess: a case report

Cerebral phaeohyphomycosis is used to describe the rare clinical syndrome of cerebral infection caused by dematiaceous (i.e. pigmented olivaceous-brown) fungi. It usually presents as brain abscess. In view of the rarity of this fungal infection and its clinical importance, we report a case of cerebral phaeohyphomycosis caused by Xylohypha bantiana. The patient presented with a seizure attack. The MRI study revealed a ring-enhancing lesion with marked perifocal edema in right high frontoparietal junction of the brain. He underwent an initial craniotomy for removal of the lesion and a second craniotomy for recurrence of the lesion 3 months later. The diagnosis was based on successful cultivation of X. bantiana from the surgical specimen and on histopathology. The patient received antifungal drug therapy of 5-flucytosine and itraconazole. He has done well without any symptoms. We think complete surgical removal of the brain abscess combined with antifungal drug therapy is the best management for this rare fungal disease.

Embolization of carotid cavernous fistula by means of direct puncture through the superior orbital fissure

PURPOSE

To embolize carotid cavernous fistulas (CCFs) by means of transorbital puncture of the cavernous sinus (CS) and the cavernous segment of the internal carotid artery (ICA) through the superior orbital fissure.

MATERIALS AND METHODS

Five patients with CCF were treated with embolization of the CS, and six were treated with embolization of both the CS and the cavernous portion of the ICA after transorbital puncture. All except one had previously undergone occlusion of the ipsilateral proximal ICA before direct transorbital puncture.

RESULTS

The fistulas in these cases were all obliterated completely. Only two patients had temporary ptosis. No other remarkable complications were noted. The patent ICA on the side of the fistula in one patient remained patent after embolization.

CONCLUSION

Direct transorbital puncture through the superior orbital fissure is an alternate treatment for CCF, especially when the ipsilateral ICA has been occluded.

Percutaneous transluminal angioplasty of neck vessels

BACKGROUND

Although surgical endarterectomy or bypass is regarded as the treatment-of-choice for extracranial cerebral vascular stenosis, percutaneous transluminal angioplasty (PTA) has its role as an alternative procedure for symptomatic patients refractory to medical therapy and/or for whom surgical treatment is contraindicated.

METHODS

Occlusive blood vessels were first identified by neurologic, ultrasonic and angiographic studies. Patients were premedicated with heparin and corticosteroid. From a transfemoral approach, double lumen balloon dilatation catheter was guided across the area of stenosis, and inflated two or three times to produce dilatation. Following PTA, patients received anticoagulants and corticosteroid for a period, and were followed by clinical examination, Doppler blood-flow and angiographic studies.

RESULTS

Seventeen patients undergoing 26 procedures were included in this study. The lesions involved subclavian artery in nine cases, common carotid artery in seven, internal carotid artery in five and proximal vertebral artery in five. Digital subtraction angiography (DSA) was done immediately after PTA and showed improvement of stenotic segment (residual stenosis < 30%) in 22 vessels. Restenosis occurred in two cases of subclavian artery PTA six months later. There were three complications, including TIA in two cases and hematoma at the puncture site in one case. Clinically, symptomatic improvement was obtained in 13 cases.

CONCLUSIONS

In patients with significant atherosclerotic stenosis of neck vessels, PTA is a beneficial procedure for improving blood flow to brain circulation and for alleviating symptoms.

Computed tomography evaluation of chronic paranasal sinusitis

BACKGROUND

Although chronic paranasal sinusitis has been recognized and diagnosed more frequently in recent years, it is still one of the most frequently overlooked disease and a significant source of morbidity and economic loss. Therefore, a further detailed analysis of its clinical pictures and computed tomographic (CT) presentations is necessary for better understanding.

METHODS

We collected 230 cases in recent two years and studied their CT manifestations.

RESULTS

The pathological changes of sinusitis on CT were classified into four groups: mucosal thickening, mucosal thickening combined with fluid level, fluid level only, and total sinus opacification, in increasing frequency. Maxillary sinus was the most commonly involved sinus. Focal high density areas were noted in 17 sinuses. Ten of them were operated and revealed only thick mucous without evidence of calcification or fungal infection. There was no correlation between the disease duration and the number of sinuses involved.

CONCLUSIONS

CT is the image modality of choice in evaluating patients with chronic paranasal sinusitis.

N-butyl-2-cyanoacrylate for embolisation of carotid aneurysm

We report the use of an N-butyl-2-cyanoacrylate (NBCA) mixture for embolisation of six cases of carotid aneurysm after detachable balloons, and/or microcoils had been placed in the aneurysm. The mixture was injected into the aneurysm to prevent delayed bleeding or distal migration of the balloons, or microcoils. No subarachnoid haemorrhage or distal migration of the balloons or microcoils occurred up to 4.5 years after embolisation. Reflux of the NBCA mixture into the parent artery occurred in one patient, who had a neurological deficit which recovered in a month. NBCA mixture may be useful in embolisation of intracranial or skull base arterial aneurysms, for reducing the size of remaining lumen in an aneurysm at high risk of rebleeding which accommodate no more balloons or microcoils, or preventing possible delayed migration of balloons or microcoils. However, prevention of leakage of the mixture into the parent artery remains a problem.

Posterior cranial fossa tumours in childhood

We reviewed clinical and CT findings in 133 posterior cranial fossa tumours in children. All had histological diagnosis, apart from 20 cases of brain stem glioma. The majority were intra-axial tumours, including 53 medulloblastomas (40%), 31 cerebellar astrocytomas (23%), 28 brain stem gliomas (21%), 14 ependymomas (11%), and single cases of ganglioglioma, haemangioblastoma and teratoma. Extra-axial tumours formed only 3%, including 2 chordomas and 2 schwannomas. The clinical data and CT findings are reviewed. Cerebellar astrocytoma involved the sexes equally, while medulloblastoma, brain stem glioma, and ependymoma were more common in males. Most cerebellar astrocytomas were in the midline, and presumably arose from the vermis. The frequency of calcification was similar to that in previous reports, being highest in ependymoma (69%), followed my medulloblastoma (29%), cerebellar astrocytoma (17%), and brain stem glioma (8%).

Spinal dural arteriovenous anomalies

The clinical data, radiologic findings, and treatment in 14 cases of spinal dural arteriovenous (AV) anomaly were reviewed. All patients had typical findings of feeding artery, nidus, and draining vein on spinal angiograms. Radiologic diagnosis of spinal AV malformation was first made after myelography in 13 cases and after magnetic resonance (MR) imaging in one case. Thirteen patients underwent embolization; one patient underwent repeat embolization 14 months after the first procedure. The other patient underwent surgical ligation. All patients had clinical improvement after treatment. A high index of clinical suspicion, a complete myelographic examination or an MR image of good quality, and a properly performed complete spinal angiographic study are important for early diagnosis. Embolization may be the treatment of choice. For best results, the feeding artery next to the nidus and the draining vein close to the nidus should be occluded, and the nidus itself should be obliterated.

Aspergillosis of the paranasal sinuses

The CT appearances of 13 cases of pathologically proven aspergillosis involving paranasal sinuses were reviewed. Symptoms included rhinorrhea, nasal obstruction, headache, facial pain and foul smell from the nose. At operation, these lesions appeared yellowish, brownish, grey or black in colour, and contained dirty or muddy material. Microscopic examination of the tissue removed showed an Aspergillus ball with chronic inflammation but without invasion of the nasal or sinus mucosa in 6 cases, and tissue invasion with necrosis and inflammation in 7. The structures involved, in order of frequency, were: maxillary sinus, nasal cavity, ethmoid sinus, orbit and cavernous sinus. The orbit was involved in 2 cases, therefore categorized as invasive; the other 11 cases were non-invasive as judged by CT. Calcification was seen in the lesions of 9 cases. In most cases the adjacent bony structures showed areas of erosion and sclerosis. Aspergillosis should be suspected in the presence of a mass in the paranasal sinuses or nasal cavity with calcification within it, which may not appear solid or dense and is separate from the walls of the sinus.