Immediate versus delayed coronary grafting after streptokinase treatment. Postoperative blood loss and clinical results

Of all patients with acute evolving myocardial infarction treated surgically at Duke University Medical Center between 1984 and 1986, 27 patients given high doses (greater than 1.5 million units) of streptokinase preoperatively were studied. Eleven patients who received streptokinase had coronary bypass grafting 12 hours after thrombolytic therapy (early hours), eight patients between 12 and 72 hours (delayed), and eight patients beyond 72 hours (late hours). Seventeen patients who underwent coronary bypass grafting within 6 hours of the onset of symptoms, without preoperative streptokinase, were included as control patients. Only the patients having early operation had significantly greater postoperative blood loss; postoperative use of red blood cells; fresh-frozen plasma; cryoprecipitate; prolonged postoperative prothrombin time; and prolonged partial thromboplastin time. Patients having delayed or late operations did not differ significantly from patients not receiving streptokinase. Only the interval between time of streptokinase administration and operation could account for the coagulopathy and the postoperative bleeding complications in the early group. Patients in the early group had a higher in-hospital mortality (27% versus 6% for the non-streptokinase group) and major noncardiac morbidity (36% versus 12% for the non-streptokinase group). Patients in the delayed and late groups had minimal postoperative complications and no mortality. Observations were not explained by differences in total ischemic time, number of angioplasty failures, or number of patients with cardiogenic shock between the early group and the non-streptokinase group. Postoperative bleeding and massive use of blood products seemed to be contributory factors: Two of three deaths in the patients having early operations were associated with clinical suspicion of tamponade. Patients undergoing coronary bypass grafting within 12 hours of streptokinase therapy appear to be a high-risk group in a more emergent, uncontrolled clinical setting and require aggressive monitoring and correction of coagulopathy.

1.5-T MR imaging of pituitary microadenomas: technical considerations and CT correlation

Thirty-seven patients with suspected pituitary tumors were evaluated prospectively with MR imaging at 1.5 T. MR detected a microadenoma at its correct location in all eight patients who underwent transsphenoidal surgery, while CT showed a focal abnormality in the correct location in only four of the eight patients. In patients who were clinically and endocrinologically considered to harbor a microadenoma, MR detected a focal pituitary signal abnormality in 83% and CT demonstrated a focal density abnormality in 42%. Infundibular displacement, focal gland convexity, and sellar-floor abnormality were seen equally well with CT and MR. MR imaging protocol included sagittal T1-weighted spin-echo, coronal inversion-recovery, and coronal spin-echo or cardiac-gated spin-echo images. Although inversion-recovery images were superior in detecting focal pituitary lesions, some microadenomas were better seen on T2-weighted images. Cardiac-gated spin-echo images showed focal pituitary lesions better than ungated images did. Our technique demonstrates MR's superior sensitivity to CT in detecting a pituitary microadenoma.

Acute spinal cord injury: MR imaging at 1.5 T

Thirty-seven magnetic resonance (MR) imaging studies were performed with a 1.5-T magnet and surface coils in 27 patients with suspected spinal cord injuries. Imaging was performed 1 day to 6 weeks after injury. Cord abnormalities were seen with MR in 19 patients, while skeletal and/or ligamentous injuries were seen in 21 (78%). Three types of MR signal patterns were seen in association with cord injuries. Acute intraspinal hemorrhage was seen in five patients with cord injuries and demonstrated decreased signal intensity on T2-weighted images obtained within 24 hours of injury. Cord edema and contusion had high signal intensity on T2-weighted images and were observed in 12 cases with cord injury. Neurologic recovery, determined in 16 patients, was insignificant in patients with intraspinal hemorrhage; however, patients with cord edema or contusion recovered significant neurologic function. MR at 1.5 T is extremely useful in the diagnosis of acute cord injury and also demonstrates potential in predicting neurologic recovery.

The impact-absorbing effects of facial fractures in closed-head injuries. An analysis of 210 patients

A series of 210 patients with facial fractures sufficiently severe to require cranial computerized tomography (CT) to evaluate suspected closed-head injury (CHI) was studied. The injuries were separated into five grades of severity based on neurological examination, including cranial CT. The injuries were also grouped into three categories based on facial regional involvement, using chi-square contingency table analysis. The data demonstrated that patients with upper facial fractures were at greatest risk for serious CHI. Injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild CHI with a modest likelihood of no neurological deficits. Trauma to only the mandibular region or to only the midfacial region was least likely to involve CHI.

Gunshot wounds to the head: a perspective

Craniocerebral gunshot wounds are a significant cause of injury and death in the United States. However, despite reports of occasional unexpectedly favorable outcome in surgically treated patients, these injuries have been viewed pessimistically and indeed have generally been excluded from modern studies of head injuries, which have concentrated on closed head injuries. A review of 143 victims of craniocerebral gunshot wounds admitted to Hermann Hospital, Houston, Texas, during a recent 30-month period confirmed that a few apparently neurologically devastated patients can be saved. A detailed analysis of these patients, including demographic details, general and neurological condition, anatomic injuries, laboratory findings, surgical care, neurological course, and neurological and functional outcome follows. The helpfulness of early resuscitation and appropriate criteria for surgery need to be studied using historic or randomized controls.

Interpeduncular fossa sign: CT criterion of subarachnoid hemorrhage

A retrospective study of 100 cerebral computed tomography scans interpreted as displaying subarachnoid hemorrhage was undertaken to determine the frequency of blood in the interpeduncular fossa as a useful radiographic sign. The results indicate that the interpeduncular fossa sign is second only to blood in the Sylvian fissure-circular sulcus area as a reliable indicator of subarachnoid hemorrhage on CT scans.

Unilateral pupillary distortion: a case report

A 29-year-old white man who complained of episodic pupillary distortion in his right eye brought on by strenuous exercise was found to have a segmental Horner's syndrome in association with a hypoplastic internal carotid artery.

Computed tomographic evaluation of ocular trauma

The CT scans of 10 traumatized patients with demonstrable ocular injuries were reviewed. The CT findings were correlated with the clinical findings in each case. CT manifestations of a variety of ocular and orbital injuries are reported and a systematic approach to the CT evaluation of ocular trauma is presented.

Chiasmal syndrome in sarcoidosis

Four patients had involvement of the anterior visual pathway by sarcoidosis. In two cases recognition of the systemic disease was delayed because only visual symptoms were present. Three cases had evidence of hypothalamic-pituitary axis dysfunction, with histologically proved granulomatous infiltration of this region. The chiasmal syndrome in sarcoidosis is characterized by a pattern of blindness in one eye, atrophy of the optic discs, and temporal visual field loss in the contralateral eye with variable degrees of pituitary dysfunction. The condition is medically treatable and simulates the clinical and even the roentgenographic appearance of a pituitary tumor.

Ischemic chiasma syndrome

Thirty patients with chiasma syndrome attributed to ischemic processes of various origins are described. The initial diagnosis was made after an investigation based on polytome pneumoencephalography and angiography. This diagnosis was confirmed later with the use of high-resolution computed tomography (CT) and refined angiographic techniques. The ischemic chiasma syndrome may be classified into five pathogenetic categories: (1) mechanical compression of the chiasm secondary to ectatic tortuous arteries; (2) vascular occlusion secondary to atheromatous plaque formation; (3) arachnoiditis with fibrosis; (4) arteritis of various origins; and (5) postpartum necrosis. Sophisticated neurologic procedures including magnification angiography and high-resolution CT are essential in ruling out a mass lesion and correlating the clinical and radiologic findings of this syndrome.

Meningioma of the paranasal sinuses

Meningiomas originating in the paranasal sinuses are rare. These tumors are thought to arise from embryonal arachnoid nests which were pinched off and left behind during embryonic development. We have described various radiographic findings of two patients with meningioma arising in the paranasal sinuses (frontal sinus origin in a 65-year-old female, and sphenoid sinus origin in a 26-year-old female). The paranasal origin of meningioma was accurately determined on the basis of CT and arteriography. A review of the 11 cases previously reported and our cases indicates that there are no specific clinical or radiographic findings of meningiomas of the paranasal sinuses.

Trans-sphenoidal removal of a Rathke's cleft cyst

Symptomatic Rathke's cleft cysts are uncommon. We present a case with suprasellar extension manifested by hypopituitarism and visual disturbances. The treatment was trans-sphenoidal evacuation and partial removal of the capsule. We suggest that the trans-sphenoidal approach to these lesions is usually adequate and that radical removal of the capsule is not necessary.

The value of radionuclide myelography in the evaluation of spinal arachnoiditis

On the basis of myelographic findings, spinal adhesive arachnoiditis was classified into three types: type I (peripheral or marginal), type II (central), and type III (advanced). Depending on its location and extent, it may be divided into group A (lumbar), group B (thoracic), and group C (cervical). In view of the fact that intrathecal injection both of oily and of water-soluble contrast media tends to produce spinal arachnoiditis, we have been using radionuclides for pre- and postoperative myelography to evaluate arachnoiditis. Radionuclide myelography with 131I-HSA or 111In-DTPA is a safe modality which provides useful information regarding spinal arachnoiditis.

Evaluation of cerebral infarction by computed tomography with special emphasis on microinfarction

Computed tomography has proved to be the most effective mode of evaluating cerebral infarction in 143 documented cases. This was especially true when multiple focal infarcts were present. The incidence of contrast enhancement in acute infarcts was 88%. Concomitant acute and old infarcts were observed in 20% of cases. In the acute stage of stroke, radionuclide studies are preferable to contrast angiography since the latter may aggravate the pre-existing focal ischemia. Follow-up CT and radionuclide scans were extremely useful in confirming the diagnosis and demonstrating various postinfarction sequelae.

Computed tomographic findings in cerebral hemiatrophy

The clinical, plain skull radiographic, brain scan, and CT findings of four patients with cerebral hemiatrophy are described. CT scanning is the most innocuous and most sensitive diagnostic method available to confirm the clinical diagnosis when plain skull radiographic changes are not confirmatory.

The value of computerized tomography in delineating suprasellar extension of pituitary adenoma for radiotherapeutic management

Radiotherapy plays a major role in the management of pituitary adenomas, either as a surgical adjunct or as the primary form of treatment. Small field precision techniques are utilized. The ability to employ limited field therapy and produce local control rates of 80--90% demands precise tumor localization. The extrasellar extension of pituitary adenomas has classically been demonstrated on angiographic and pneumoencephalographic examinations. Direct superior extension is accurately delineated by these examinations; lateral extension, however, is not and the total anterior-posterior extent of the tumor may be underestimated. The addition of computerized tomography significantly increases the information available in the assessment of tumor extension and the subsequent accuracy of treatment planning for radiotherapeutic purposes.

The role of ultrasonography in the diagnosis of certain neurologic disorders. A preliminary report

Ultrasonography is the most innocuous and noninvasive procedure, ideally suited for screening patients suspected of having cerebrovascular insufficiency. The Doppler ultrasound and real-time techniques complement each other. The latter can actually display a two-dimensional dynamic image of the carotid artery. B-scan can also be used in fetuses, infants, and young children for precise assessment of the size of the ventricular system. It can be used for serial follow-up evaluation of hydrocephalus. Ultrasound can be utilized in determination of the depth and width of the lumbar spinal canal. Differentiation of cystic from solid masses in the spinal canal may also be made by this modality.

The vasculature of the diaphragma sellae. A postmortem injection study

The postmortem injection study demonstrated that the main blood supply to each quadrant of the competent diaphragma sellae appears to come from the following vessels: posterior quadrant, inferior hypophyseal arteries; right and left marginal quadrant, tributaries of the intracavernous portion of the carotid artery; anterior marginal quadrant, anterior capsular arteries. When the diaphragm is incomplete or absent the inferior hypophyseal arteries are the main source of blood supply. Microscopic analysis of the vascular bed in the diaphragma sellae reveals that there are fine arterial filaments mostly in the superior layer, while venules are situated in the inferior part of the diaphragm.

The value of computed tomography in delineating suprasellar extension of pituitary adenomas

Pituitary tumors commonly produce suprasellar extension. We have found that in assessing lateral suprasellar extent, the pneumoencephalogram and arteriogram are least accurate. CT scanning significantly increases the accuracy, and it is recommended that all patients with pituitary tumors have an initial CT scan.

The value of computed tomography in the radiotherapeutic management of juxtasellar tumors

Computerized tomography has proven to be extremely useful for accurate tumor localization and precise assessment of tumor extent in the juxtasellar region. A reconstruction and display system with ACTA scanner provides three-dimensional images from the serial two-dimensional sections. With this method, one can determine the volume and actual contour of the tumor. Using the ACTA scanner, both transaxial and coronal sections of the tumor can be precisely portrayed with accurate dimensions. With the aid of CT treatment planning, we have been successfully treating such radiocurable tumors as pituitary adenomas, germinomas, craniopharyngiomas and optic gliomas.

CT evidence of grey matter calcification secondary to radiation therapy

There are four previously reported cases of post-irradiation calcification in the basal ganglia as demonstrated on the conventional skull roentgenograms. We have described two additional cases with grey matter calcification, which were demonstrated 10 and 14 yr after radiation therapy for an optic glioma and a medulloblastoma, respectively. The calcification was clearly demonstrated on CT scan, although it was not apparent on the skull roentgenogram. The extract pathogenesis of this condition is not clear. It appears, however, to be related to radiation vasculitis of the small vessels of the brain with resultant hyalinization and calcification. A long-term follow up study would be necessary to evaluate the significance and implication of post-irradiation calcification of the grey matter. CT is the most sensitive method of demonstrating the intracranial calcification in vivo.