A thrombosing, giant, distal posterior cerebral artery aneurysm in a newborn infant

Intracranial aneurysms are extremely rare in infancy. No consensus has yet been developed about the exact treatment of this rare situation. The authors report the case of a 47-day-old male infant who had multiple seizures on the same day, leading to the diagnosis of an intracranial aneurysm. The case was managed conservatively with close imaging follow-up, and the patient had a good recovery. The results of neurological examination were completely normal at the 5-year follow-up visit. These rare lesions may be suspected on the basis of clinical findings and correctly diagnosed with current neuroradiological imaging modalities. The authors believe this report contributes valuable imaging data on rare childhood aneurysms to the literature, as well as emphasizing the importance of clinical and imaging information in therapeutic decision making in children with intracranial vascular problems.

Vein of Galen aneurysmal malformation: prenatal diagnosis and early endovascular management

A prenatally diagnosed patient was referred to our hospital at 35 weeks of gestation. Antenatal ultrasonography demonstrated cardiomegaly and aneurysm of the vein of Galen. A 3,290 g male baby was delivered by elective cesarean section at 37 weeks of gestation. Physical examination was remarkable for tachypnea, hyperdynamic precordium with a continuous murmur, cranial bruit and bounding carotid pulses. Magnetic resonance angiography confirmed vein of Galen aneurysmal malformation and demonstrated the vessels feeding the aneurysm. Postnatal management included aggressive medical treatment of cardiac failure and transarterial embolization of the vessels feeding the aneurysm at 3 days of age. Posthemorrhagic hydrocephalus developed after embolization, and a ventriculo-peritoneal shunt was placed at 29 days of age. Presently, the patient is 4 years of age and has no neurological abnormality at follow-up. Vein of Galen aneurysmal malformations can cause severe morbidity and mortality in neonates. However, careful obstetric follow-up and early postnatal endovascular treatment of these malformations may lead to a favorable outcome.

Magnetic resonance spectroscopy findings in photosensitive idiopathic generalized epilepsy

Studies investigating the pathophysiology of epileptic photosensitivity indicate variable involvement of particular brain regions. Our aim was to identify metabolic differences between photosensitive idiopathic generalized epilepsy (IGE) patients and nonphotosensitive IGE patients and normal healthy subjects by using Magnetic Resonance Spectroscopy (MRS). Fourteen patients diagnosed with photosensitive IGE were investigated. The control groups consisted of 14 age- and sex-matched healthy volunteers and 14 IGE patients without photosensitivity. MRS measurements of N-acetylaspartate (NAA), choline-containing compounds (Cho), creatine (Cr) were performed in the frontal and occipital cortex and the thalamus bilaterally using a stimulated echo acquisition mode (STEAM) technique with a voxel size of 20 x 20 x 20 mm. The values of the patients with IGE were compared with those of the normal controls and within subgroups according to the clinical variables by appropriate statistical tests. Photosensitive IGE patients showed significantly decreased concentrations of NAA in the right frontal lobe and left thalamus, decreased NAA/Cr ratio in left thalamus and significantly increased concentrations of Cho/Cr ratio in the right frontal lobe and NAA/Cr in the left occipital lobe when compared to normal controls. Furthermore, left occipital NAA concentration increased and left thalamus NAA/Cr ratios were decreased from the IGE patients without photosensitivity but without reaching statistical significance. Our results support previous MR studies suggesting an asymmetrical neuronal dysfunction in favor of the dominant occipital cortex and thalamus in photosensitive IGE patients.

MR spectroscopy findings in Lafora disease

PURPOSE

Our aim was to investigate the [(1)H] MR spectroscopy (MRS) findings of Lafora Disease (LD), which is a disabling form of progressive myoclonic epilepsy.

METHODS

Twelve patients diagnosed with LD and 12 control subjects underwent MRS studies with single-voxels of 8 cc obtained in the frontal lobe, pons, and cerebellum. The metabolites and NAA/Cr, NAA/Cho, Cho/Cr, mI/Cr ratios were calculated. Subgroup analysis was also done between 5 patients with EPM2B and 6 patients with EPM2A mutations. Two investigators scored neurological symptom severity.

RESULTS

We found a statistically significant difference of NAA/Cho ratio in LD patients compared with normal controls in cerebellum (P= 0.04). In addition, both myoclonus and ataxia scores showed significant correlation with NAA/Cho ratios in the pons (P= 0.03, P= 0.04) and in the cerebellum (P= 0.04, P= 0.01), respectively.

CONCLUSION

We conclude that the cerebellum is the mostly affected structure in LD and there are significant correlations of MRS findings with some clinical parameters. The differences in the group may be related to different genetic mutations besides disease duration and other clinical variables. MRS studies could provide insights about the severity of the involvement of LD.

Localization of cerebrospinal fluid leaks by gadolinium-enhanced magnetic resonance cisternography: a 5-year single-center experience

OBJECTIVE

Intrathecal gadolinium (Gd)-enhanced magnetic resonance (MR) cisternography is a newly introduced imaging method. Two main objectives of this study were to investigate the sensitivity of Gd-enhanced MR cisternography for presurgical localization of cerebrospinal fluid (CSF) leaks in patients with CSF rhinorrhea and to study the potential long-term adverse effects of intrathecal Gd application.

METHODS

Fifty-one patients (19 women; mean age, 36.2 yr) with CSF rhinorrhea were included in the study. A total of 0.5 ml of Gd was injected into the lumbar subarachnoid space. T1-weighted MR cisternographic images were obtained to detect CSF leakage. The patient's neurological states and vital signs were recorded for the first 24 hours after the procedure. Neurological evaluations were repeated 1, 3, and 12 months after the procedure. The patients were followed for at least 3 years with annual neurological examinations.

RESULTS

Gd-enhanced MR cisternography demonstrated CSF leaks in 43 of the 51 patients. The sensitivity of Gd-enhanced MR cisternography for localization of CSF leaks was 84%. Forty-four patients underwent surgery to repair dural tears. Surgical findings confirmed the results of Gd-enhanced cisternography in 43 of the 44 patients who underwent surgery (98%). Eight patients with negative Gd-enhanced MR cisternography had no active rhinorrhea at the time of procedure, and seven of them did not need surgery. None of the patients developed an acute adverse reaction that could be attributed to the procedure. None of the patients developed any neurological symptoms or signs caused by intrathecal Gd injection during a mean follow-up period of 4.12 years.

CONCLUSION

Gd-enhanced MR cisternography is a sensitive and safe imaging method for detection of CSF leaks in patients with rhinorrhea.

An unspecified clinical syndrome in mentally retarded patients with bilateral mesial temporal sclerosis

PURPOSE

The association of febrile convulsions and mesial temporal sclerosis (MTS) is a well-known phenomenon. However, the effects of mental retardation on febrile convulsions and MTS have not been investigated previously. The aim of this study is to investigate the relation of mental retardation to febrile convulsions especially as febrile status epilepticus and MTS.

METHODS

We describe three patients who have bilateral mesial temporal sclerosis with mental retardation and a history of febrile status epilepticus (FSE), and have clinically typical mesial temporal lobe epilepsy (MTLE).

RESULTS

The FRSB and neuropsychology test revealed executive dysfunction in patients whose bilateral MTS had a benign course, which was unexpected.

CONCLUSIONS

Febrile status epilepticus might have a role in the development of their mental retardation. This study also pointed out that MTS might have subtypes as a result of our attempts at distinguishing patients with MTS.

Evaluation of hemodynamic perfusion MR images

Perfusion normally refers to the delivery of blood at the level of capillaries. Hemodynamic perfusion magnetic resonance (MR) imaging has been used in clinics for a series of applications including tumor characterization (histological type diagnosis and grading), diagnosis and the follow up of stroke, and several other disorders. For this study a platform to investigate the theoretical basis of perfusion imaging was developed. Using dynamic measurements of contrast agents in magnetic resonance imaging (MRI) relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), and mean transit time (MTT) are calculated. These three parameters are quantized, and displayed as color images for diagnostic and follow up studies. The comparative studies in MR perfusion must address issues such as; image registration, region of interest (ROI) selection, threshold identification and quantization of rCBV, rCBF and rMTT. The evaluation process involved the comparison of the diagnostic capabilities of the three perfusion images (rCBV, rCBF, MTT). Digital Substraction angiography was used as the gold standard in these comparisons. The study group comprises 16 patients with the diagnosis of subarachnoid bleeding and intracranial aneurysms. The proposed cerebral MR perfusion analysis system has been accepted by the radiologists as a useful tool for their perfusion studies and clinical evaluation.

Stroke in childhood: experience in Istanbul, Turkey

Our objective was to characterize the etiologic factors and outcome for stroke in children. We retrospectively reviewed the charts of patients between the ages of 40 days and 94 months (36.5 +/- 23.7 months) with stroke seen at Istanbul Medical Faculty, Department of Pediatrics between January 1995 and December 2003. We found 79 cases of stroke: 57 ischemic and 22 hemorrhagic strokes. Seventeen children had vitamin K deficiency dependent hemorrhage. In 14 children stroke occurred as a complication of cardiac disease, 7 had moyamoya disease, 3 had protein C deficiency, 2 had thalassemia, 2 had hyperhomocysteinemia (methylene tetrahydrofolate reductase gene mutation), 2 were heterozygote for factor V Leiden, 3 had Down's syndrome, 1 was diagnosed with antiphospholipid syndrome, 1 had glycogen storage disease, and in 28 children no underlying cause could be found. Multiple risk factors were found in 4 children. The outcome in all 79 stroke patients was as follows: asymptomatic 60%; symptomatic epilepsy or persistent neurologic deficit 37%; death 3%; and recurrent stroke 5%. Thus, an underlying cause for stroke was identified in 65% of the children in the study group; 40% of the children either died or suffered motor and/or cognitive sequelae.

Anesthesia following overfilling of a root canal sealer into the mandibular canal: A case report

The surgical treatment of a case of anesthesia that occurred with the extrusion of Endomethasone root canal sealer into the mandibular canal is presented. Endomethasone is a neurotoxic root canal sealer containing paraformaldehyde and eugenol. The literature indicates immediate surgical decompression on the extrusion of Endomethasone into the mandibular canal. In our case, the decompression surgery was done 3 weeks after the endodontic mishap. The nearly complete resolution of anesthesia 4 months following the decompression surgery suggests that the neurotoxic effects of Endomethasone are still reversible after 3 weeks.

An intrasellar germinoma with normal cerebrospinal fluid beta-HCG concentrations misdiagnosed as hypophysitis

A patient with an intrasellar germinoma leading to pituitary stalk thickening is reported. The patient, a 24-year old woman, presented with hyperprolactinemia, secondary hypothyroidism, and hypogonadotropic hypogonadism with no evidence of diabetes insipidus. Cerebrospinal fluid (CSF) examination revealed an increased number of lymphocytes and histiocytes. Although beta-HCG concentration was normal (<2 mIU/mL) in the CSF, increased beta-HCG concentration was detected in the serum. Systemic glucocorticoid treatment led to a decrease in CSF cell count, but no regression of the sellar mass was noted. A diagnostic biopsy was performed and showed an intrasellar germinoma. The patient underwent conventional radiotherapy. Complete resolution of the mass lesion and normalization of beta-HCG concentration in the serum were observed three months after radiotherapy. The presence of intrasellar mass lesion in association with pituitary stalk thickening may cause difficulties in the differential diagnosis. Histopathological examination is essential in equivocal cases in order to reach accurate diagnosis and apply the most appropriate therapy.

[Radiological imaging in spinal pain]

Spinal pain is a very common disorder in the clinical practice and an important cause of man-power loss. Radiological investigations are commonly used to identify the underlying pathology of spinal pain. Along with the technological advancements, the radiological techniques have improved a lot during the last few decades. This review explains the use, advantages and restrictions of direct roentgenogram, myelograpy applications, computed tomography, magnetic resonance imaging, discography and spinal angiography which are commonly used radiological techniques in the diagnosis and follow-up of spinal pain conditions. Better understanding of the indications, advantages and disadvantages of such radiological techniques by the clinicians will improve the clinical output while optimizing the problems such as x-ray exposure and economical burden.

Surgical results in pediatric Spetzler-Martin grades I-III intracranial arteriovenous malformations

OBJECTS

The goal of cerebral arteriovenous malformation (AVM) therapy in pediatric patients should be complete resection or obliteration of the AVM to eliminate subsequent hemorrhage, because of high mortality and morbidity rates related to hemorrhage in addition to the longer life expectation. Despite advances in Gamma knife radiosurgery and in endovascular embolization, surgical resection is still the gold standard for treating cerebral AVMs.

METHODS

Between 1986 and 2003, 20 children were surgically treated for cerebral AVMs. The AVMs were graded I, II, and III using the Spetzler-Martin (S-M) Grading Scale. Good recovery was achieved in 18 out of 20 patients (90%) and only 1 patient was moderately disabled (5%). There was one mortality (5%) related to the preoperative deep comatose state of the patient. The total obliteration rate was 89% (17 out of 19).

CONCLUSION

For S-M grade I-III AVMs, surgical resection is the treatment of choice, considering its high cure rate and low morbidity and mortality rates.

Quantitative proton MR spectroscopic findings of cortical reorganization in the auditory cortex of musicians

BACKGROUND AND PURPOSE

Brain has a capacity for reorganization that enables use-dependent adaptations to acquire skills. Previous studies demonstrated morphometric and functional use-dependent changes in the brains of musicians. The purpose of this study was to investigate the differences in metabolite concentrations in the planum temporale, an area strongly associated with the processing of music perception, between trained musicians and non-musicians. We hypothesized that the microscopic changes leading to use-dependent adaptations in brain might cause neurometabolite changes that could be detected with quantitative proton MR spectroscopy.

METHODS

We performed quantitative proton MR spectroscopy in the left planum temporale of 10 musicians (six men and four women; age range, 20-37 years) and in those of 10 age- and sex-matched control subjects who had no musical training. We calculated the major metabolite concentrations in the left planum temporale.

RESULTS

The difference in N-acetylaspartate (NAA) concentrations between the musicians and the non-musician control subjects was statistically significant (P <.01). No significant difference was noted in the choline and creatine concentrations between the musicians and the non-musician control subjects (P >.05). The NAA concentration of the musicians correlated with the total duration of musical training and activity (r=0.733, P <.05).

CONCLUSION

Long-term, professional musical activity caused significant changes in the neurometabolite concentrations that might reflect the physiologic mechanism(s) of use-dependent adaptation in the brains of musicians.

Angiography-induced closure of perimedullary spinal arteriovenous fistula

Type 4 spinal vascular malformations are called perimedullary arteriovenous fistulae, in which there is a shunt between a radicular artery and intradural veins. We report the spinal MR imaging and angiography findings of the angiography-induced closure of a type 4 spinal vascular malformation.

[A case of superior sagittal sinus thrombosis after closed head injury]

Superior sagittal sinus thrombosis (SSST) is a rare entity, most often arising from infections, dehydration, and hematologic disorders. Development of this condition secondary to trauma is extremely rare. In this report, a 13-year-old boy who developed SSST following a closed head injury is presented. Imaging studies showed SSST caused by a depressed skull fracture. Neurologic examination of the patient was normal other than bilateral papillary stasis. He was treated with antiedematous and anticonvulsant drugs. Magnetic resonance venography obtained eight months after the diagnosis showed unoccluded superior sagittal sinus, neurologic examination findings were normal, as well.

Skull Base Plasmacytoma in a Patient with Light Chain Myeloma

Skull base involvement of plasmacytoma is reported in a patient with light chain myeloma. A 39-year-old man was admitted after experiencing paresthesia on the left side of the face and left arm, intermittent diplopia, and hoarseness for 2 years. Cranial magnetic resonance imaging revealed a large midline mass extending from the middle and posterior skull base into the upper two cervical vertebrae. An extramedullary plasmacytoma associated with light chain multiple myeloma was diagnosed after biopsy of the mass and laboratory investigations. The imaging findings and clinical features associated with this rare site of extramedullary plasmacytoma involvement are reported.

Single-voxel proton MR spectroscopy in toluene abuse

Inhalation of toluene, which is an organic solvent, causes toxic encephalopathy characterized by cognitive impairment, cerebellar and extra-pyramidal symptoms. We studied cranial MR images and single-voxel MR spectroscopy of 22 toluene abusers and age-matched control subjects. The mean age of the abusers and mean duration of abuse were 18,1 years and 47 months, respectively. We got three MR spectra from the centrum semiovale, cerebellum and thalamus by using STEAM sequence with a TE value of 30 ms. N-acetyl aspartate (NAA)/Creatine (Cr), Choline (Cho)/Cr, myo-inositol (mI)/Cr peak integral ratios were calculated. NAA/Cr in the cerebellum and centrum semiovale of the abusers were significantly lower than those of the control subjects. mI/Cr in centrum semiovale and cerebellum were higher in toluene abusers. No significant difference was found in the metabolite ratios of the thalami. The association of NAA/Cr and mI/Cr ratios in cerebellum and centrum semiovale with the duration of abuse was significant. Normal level of NAA in thalamus, which was a neuron rich gray matter structure, might imply that toluene inhalation did not cause direct neuronal injury. Selective reduction of NAA and increased level of mI in white matter supported the theory of that axonopathy and gliosis were the main mechanisms of pathophysiology in chronic toluene encepholopathy. Insignificance of elevation of Cho/Cr ratios demonstrated that toluene inhalation did not cause active demyelination.

Obsessive-compulsive disorder after epilepsy surgery

It is a well-known fact that after epilepsy surgery (ES) preexisting psychopathology may deteriorate or de novo psychopathological syndromes, mainly of a depressive and psychotic nature, may appear. Previously, recovery of obsessive-compulsive disorder (OCD) after ES has been reported in patients who had comorbid OCD preoperatively; however, there have been no reports on the appearance of de novo OCD interfering with daily living activities post-ES. This is the first report of OCD after ES in patients with mesial temporal lobe epilepsy (MTLE). Five patients with MTLE were identified with obsessive personality traits before surgery. Within the first 2 months after ES, two of these MTLE patients fulfilled OCD diagnostic criteria. These OCD patients were not any different from the other three patients with respect to age, age of onset of epilepsy, seizure types, and seizure frequency. All patients stopped having seizures postoperatively, but the OCD patients had worse quality of life postoperatively than preoperatively. Our findings show that those patients with obsessive traits preoperatively should be carefully monitored after ES.

Single-voxel MR spectroscopy and diffusion-weighted MRI in two patients with l-2-hydroxyglutaric aciduria

l-2-Hydroxyglutaric aciduria is a rare inherited, neurometabolic disorder. The underlying metabolic defect and the pathophysiology of l-2-hydroxyglutaric aciduria have not yet been defined. We present MR spectroscopy and cranial MR imaging findings, including diffusion-weighted sequences in two male siblings (aged 10 and 12 years). MR spectroscopy revealed a multiplet at 2.10-2.50 ppm and two broad peaks at 0.9-1.6 ppm. The multiplet at 2.10-2.50 ppm might have been created by elevated glutamate and glutamine or l-2-hydroxyglutaric acid itself, which has a similar chemical structure to glutamate. Diffusion-weighted images demonstrated increased diffusion of water molecules in the white-matter lesions.

MRI cisternography with gadolinium-containing contrast medium: its role, advantages and limitations in the investigation of rhinorrhoea

Our purpose was to evaluate the utility of intrathecal gadopentetate dimeglumine -enhanced magnetic resonance cisternography (GdMRC). We injected 0.5 ml contrast medium into the subarachnoid space via lumbar puncture in 20 patients with suspected cerebrospinal fluid (CSF) rhinorrhoea. MRC showed CSF leakage in 14 patients with rhinorrhoea at the time of the examination, into the ethmoid air cells in nine, the sphenoid sinus in three and the frontal sinus in two cases. In 12 of these the site leakage was confirmed during surgical repair of the fistula. No leakage was observed in four patients with intermittent rhinorrhoea, not present at the time of the examination. GdMRC showed leakage in two patients with negative CT cisternography. GdMRC may prove better than CT cisternography, especially with slow CSF flow. We also showed low-dose GdMRC to be a feasible and relative safe way of confirming the presence of and localising active CSF leaks prior to surgical repair.

[Clinical and magnetic resonance imaging findings in patients with surgically treated mesial temporal sclerosis]

PURPOSE

Mesial temporal sclerosis (MTS) is one of the leading causes of medically intractable complex partial seizures. Magnetic resonance imaging (MRI) and clinical findings in seventeen patients who had surgery for medically intractable mesial temporal lobe epilepsy (MTLE) are presented in this report.

MATERIALS AND METHODS

17 patients (9 females and 8 males) aged 19-35 years with clinically and electrophysiologically proven MTLE have been included in the study. Age at seizure onset was six months to 17 years, frequency of seizures 4-20 times/month, and duration of medical treatment 10-28 years with no response. MRI and volumetry of the mesial temporal structures were performed in all patients.

RESULTS

On preoperative MRI and volumetry, pathologic signal, loss of internal structures and atrophy were present in the right hippocampus in twelve cases and left hippocampus in five. The hippocampal head and body were involved in ten cases and all three parts in seven. The Wada test was performed in three cases showing that memory and speech functions were controlled by the noninvolved side. All patients underwent surgery. The histopathological examination result was MTS in all cases. In the postoperative follow up period of one to 24 months, 12 patients were assessed as class I and II, and seven as III according to the Engel Classification.

CONCLUSION

MRI and volumetry are among the most important tools in the preoperative diagnosis of MTS. All patients have benefited from surgery, verifying the preoperative clinical and MR imaging diagnosis. Interpretation of MR findings is important in determining surgical candidates and success of surgery in MTS, which is a major cause of medically intractable temporal epilepsy.

Imaging in tuberculosis of the skull and skull-base: case report

We report a 19-year-old girl, who presented with headache and tonic/clonic seizures. Imaging revealed a lytic parietal skull lesion with an adjacent epidural mass, masses in the right parietal lobe and a posterior skull-base mass. The diagnosis of tuberculosis was made after resection of the extradural mass and later verified with culture of Mycobacterium tuberculosis. The parenchymal and skull-base lesions resolved following antituberculous treatment. We present CT, scintigraphic, angiographic and MRI findings.

A new MRI method for the quantitative evaluation of extraocular muscle size in thyroid ophthalmopathy

In cross section, extraocular muscles are more or less elliptical, with short and long diameters. We studied the ratio (R) of short to long diameter and investigated its use in quantitative assessment of the extraocular muscles in patients with Graves's disease. We measured the diameters on T1-weighted axial and coronal MRI and computed R for each extraocular muscle in 80 patients without and 40 with Graves's disease. We compared the measurements and R of the right and left orbits, and of men and women. The short diameter of all extraocular muscles apart from the superior oblique showed significant differences between men and women, and that of the inferior rectus varied significantly with age. R, however, was unrelated to sex or age. All patients with Graves's disease and an increased short diameter also had an increased R, but 6% of the muscles showed an increase in R, even though their short diameter was within the normal range.

Case report: Spinal cord herniation into a mediastinal neurenteric cyst: CT and MRI findings

Split notochord syndrome is a spectrum of congenital spinal malformations that develops due to an adhesion between endoderm and ectoderm causing the "splitting" of notochord. Neurenteric cyst is one of the components of split notochord syndrome. We report CT and MRI findings of an unusual case with thoracal spinal cord herniation into a mediastinal neurenteric cyst.

Cranial MR findings in chronic toluene abuse by inhalation

BACKGROUND AND PURPOSE

Chronic abuse of toluene by inhalation causes variable white matter changes and thalamic hypointensity on T2-weighted MR images. The purpose of our study was to assess cranial MR findings in a large series of patients who chronically abuse toluene-containing solvents to investigate the factors causing the qualitative variability of white matter changes and thalamic hypointensity.

METHODS

We studied the neurologic signs, symptoms, and cranial MR findings in 41 patients who chronically abused thinner, a toluene-containing solvent. We classified white matter changes as diffuse or restricted. We tested the associations of the development of white matter lesions and thalamic hypointensity with patient age at onset of abuse and duration of abuse.

RESULTS

MR images revealed white matter lesions in 46% of the patients, atrophic dilatation of ventricles and sulci in 27%, and thalamic hypointensity in 20%. White matter changes were restricted in 53% and diffuse in 47%. The development of white matter changes and thalamic hypointensity were significantly associated with duration of abuse longer than 4 years (P <.05 and P <.01, respectively).

CONCLUSION

White matter changes seem to start in the deep periventricular white matter, and they spread into peripheral white matter, causing the loss of gray matter-white matter differentiation with continued toluene abuse. The deposition of iron due to demyelination and axonal loss is the most probable mechanism for the thalamic hypointensity found in solvent abusers.

Clinical features of tuberous sclerosis cases

Tuberous sclerosis (TS) is an autosomal dominant, multisystemic and neurocutaneous disease with high spontaneous mutation rate, and it mostly involves the skin, brain, kidneys, heart and the eyes. This study included 35 patients diagnosed with tuberous sclerosis and aged 6 months to 17 years, with a mean age of 6.5+/-4.8 years. The most frequently observed manifestations were those of the skin (97.1%) and of the central nervous system (seizures 94.2%, mental retardation 51.4%), followed by renal (32.2%), cardiac (25.8%) and ocular (22.5%) manifestations. Among cutaneous manifestations, hypomelanotic macules (94.3%), facial angiofibromas (40%), shagreen spots (20%), fibrous plaques on the forehead (5.7%) and ungula fibromas (5.7%) were observed. Tonic seizures (37.1%) and infantile spasms (21.2%) accounted for majority of seizures. Neurophysiological development was normal in 25.6% of cases, retarded in 51.4% and borderline in 23%. Thirty-four patients had typical pathological findings on magnetic resonance imaging (MRI). In conclusion, the earliest and most frequent complaint is seizure in cases with TS. Careful investigation for hypomelanotic macules and other skin manifestations typical for TS in cases presenting with convulsion makes early diagnosis possible and obviates unnecessary investigations.

Thoracocervical dorsal dermal sinus associated with multiple vertebral body anomalies

Congenital dermal sinus is a type of closed spinal dysraphism. Cervical and thoracic regions are the rare sites for dorsal dermal sinuses. Dermal sinuses are frequently associated with dermoid or epidermoid tumor and osseous abnormalities such as bifid spinous process. The association of dorsal dermal sinuses with vertebral body anomalies is very rare. We present MR imaging features of a case of thoracocervical dorsal dermal sinus associated with multiple vertebral body anomalies.

Pneumococcal vertebral osteomyelitis: a unique case with atypical clinical course

STUDY DESIGN

A case report.

OBJECTIVES

To report and discuss a case of pneumococcal vertebral osteomyelitis with meningitis in a previously healthy 51-year-old immunocompetent woman who presented with acute onset lower back pain.

SUMMARY OF BACKGROUND DATA

To the authors' knowledge, pneumococcal vertebral osteomyelitis with meningitis in an immunocompetent person with no other predisposing factor has not been reported previously.

METHODS

The patient was diagnosed to have pneumococcal meningitis 10 days after the onset of acute and severe lower back pain. Significant improvement of clinical symptoms from meningitis was achieved with appropriate antimicrobial treatment. Lumbar CT and MRI scans were performed on persistence of fever and lower back pain. Loss of height and peridiscal inflammation at L3-L4 and epidural and bilateral psoas abscesses were detected.

RESULTS

Diagnosis of pneumococcal vertebral osteomyelitis was established after evaluation of the material obtained from CT-guided aspiration of the psoas abscess and biopsy of the L3 body. With appropriate antimicrobial treatment, the patient's complaints resolved completely.

CONCLUSION

To the authors' knowledge, this is the first reported case of pneumococcal vertebral osteomyelitis with meningitis.

Primary hydatid disease of the femur: unsuspected and incidental MRI findings with long-term curative results on medical treatment alone

This report describes the early magnetic resonance imaging (MRI) findings and long-term follow-up results of albendazole treatment in a 16-year-old girl with primary hydatid disease of the femur diagnosed incidentally during the course of a post-traumatic knee infection. As far as we know, this is the first report of the early MRI findings and long-term outcome of medical treatment in primary hydatid disease of the femur in this age group.

Coupling of RYR1 and L-type calcium channels via calmodulin binding domains

In skeletal muscle the L-type Ca2+ channel directly controls the opening of the sarcoplasmic reticulum Ca2+ release channel (RYR1), and RYR1, in turn, prevents L-type Ca2+ channel inactivation. We demonstrate that the two proteins interact using calmodulin binding regions of both proteins. A recombinant protein representing amino acids 1393-1527 (D1393-1527) of the carboxyl-terminal tail of the skeletal muscle L-type voltage-dependent calcium channel binds Ca2+, Ca2+ calmodulin, and apocalmodulin. In the absence of calmodulin, D1393-1527 binds to both RYR1 and a peptide representing the calmodulin binding site of RYR1 (amino acids 3609-3643). In addition, biotinylated R3609-3643 peptide can be used with streptavidin beads to pull down [3H]PN200-110-labeled L-type channels from detergent-solubilized transverse tubule membranes. The binding of the L-type channel carboxyl-terminal tail to the calmodulin binding site on RYR1 may stabilize the contact between the two proteins, provide a mechanism for Ca2+ and/or calmodulin regulation of their interaction, or participate directly in functional signaling between these two proteins. A unique aspect of this study is the finding that calmodulin binding sequences can serve as specific binding motifs for proteins other than calmodulin.

Do unilateral ablative lesions of the subthalamic nucleu in parkinsonian patients lead to hemiballism?

We report the safety results in nine patients with advanced idiopathic Parkinson's disease (PD) who underwent ablative surgery of unilateral subthalamic nucleus (STN). In eight patients, surgical objectives were attained without induction of abnormal involuntary movements or other adverse effects. One patient developed transient hemiballistic movements which improved within 2 weeks after surgery. Assessment at 2 weeks to 20 months postoperatively revealed no long-term adverse effects. We conclude that hemiballism following unilateral ablation of STN in patients with PD is a rare phenomenon, and unilateral ablative lesions of STN can be performed safely.

Cervical Castleman's disease: imaging findings

Castleman's disease, a lymphoproliferative disease of unknown etiology, rarely causes a neck mass and may mimic granulomatous, inflammatory and metastatic lymph nodes, or lymphoma with its nonspecific imaging findings. Definitive diagnosis and treatment is possible with complete surgical resection. Imaging findings of a case with Castleman's disease detected during multinodular goiter surgery and later verified through excisional biopsy are presented. This report, as far as we know, is the first evaluation of the disease with sonography, Doppler sonography, CT, MR imaging, and digital subtraction angiography (DSA) findings.

Cerebrospinal fluid dynamics of the cava septi pellucidi and vergae. Case report

This case involved a 26-month-old boy who had recurrent hemorrhagic venous infarction caused by venous sinus occlusion. Distension and enlargement of the cavum septi pellucidi (CSP) and cavum vergae (CV), along with hydrocephalus, was detected during the course of the disease and was observed to regress together with resolution of the venous occlusion. Venous hypertension caused by sinus occlusion was thought to be responsible for the disturbed resorption of cerebrospinal fluid (CSF) in the CSP and CV in this patient. This case is unique because it is the first one to support the hypothesis of resorption of CSF in the cava by a pressure gradient involving the septal capillaries and veins.

Recent experience with Moyamoya disease in Turkey

A series of moyamoya patients is presented. Angiographic findings, outcome of revascularization surgery and a young case with moyamoya disease and hyperphosphatemia are reported. Thirteen patients (6 males and 7 females; age range 2-50 years) were included in the study group. Findings of the patients at presentation were intracranial haemorrhage in two adult cases and sequelae of cerebral ischemia in the rest of the group. One young girl had hyperphosphataemia. Angiography showed distal internal carotid or proximal anterior and middle cerebral artery stenosis, unique collaterals, microaneurysm of the posterior lateral choroidal artery and flow-related changes in the posterior circulation. In 3 patients, encephalo-duro-arterio-synangiosis (EDAS) and burrholes were performed at surgery. Follow-up angiograms of these patients showed revascularization. Moyamoya, a rare but potentially devastating disease, must be addressed as a cause of haemorrhagic and ischaemic cerebral events.

Vertebral sarcoidosis: imaging findings

Sarcoidosis is a multisystemic disease of unknown aetiology characterised by noncaseating granulomatous inflammation with varying presentation and prognosis. Osseous disease reported in 1-13 % of cases commonly involves hands and feet; however, vertebral sarcoidosis is rare. This report describes the radiologic, CT, MRI and radionuclide imaging findings of vertebral involvement of a case with sarcoidosis.

Stereotactic surgery in the management of brain abscess

BACKGROUND

Bacterial brain abscesses can be diagnosed and treated with stereotactic aspiration.

METHODS

From 1991 to 1997 we have used computed tomography-guided stereotactic aspiration to diagnose and treat 21 patients with a total of 58 bacterial brain abscesses. The ages of the patients ranged from 4 to 72 years (median 25 years); 11 of these 21 patients had multiple abscesses. The number of abscesses per patient with multiple abscesses ranged from 2 to 9, all located deep in subcortical white matter.

RESULTS

All patients underwent stereotactic surgical drainage and an 8-week intravenous antibiotic medical treatment. Of the 58 abscesses, 23 were aspirated. Of these 23 abscesses, 19 were radiologically stage III or IV and four were stage I or II. Pathological examination confirmed radiological staging in 19 patients (83%). Except for the three patients who have mild residual hemiparesis and one patient recovering from ataxia, all patients had complete neurological recovery.

CONCLUSIONS

Computed tomography-guided stereotaxy achieved all the objectives of management; namely, ascertaining the diagnosis, draining the content of the mass, and obtaining pus for accurate bacteriological diagnosis without morbidity. Stereotactic aspiration combined with an 8-week intravenous antibiotic regimen has yielded an effective therapeutic result in all of our abscesses, small or large, solitary or multiple, superficial or deep-seated. A high radiological-pathological correlation was also deduced from this study.

Computed tomography scan of the liver

Computed tomography (CT) examination of the liver has continually been improving our understanding and assessment of liver disease since its introduction into clinical practice. The hallmark of the advances in CT imaging has undoubtably been helical CT, which made a great impact on body imaging with its many advantages, the most important being optimization of multiphasic enhanced studies, CT hepatic angiography (CTHA), and CT arterial portography (CTAP). Various applications and protocols of CT imaging rendering advantages and drawbacks to the technique are highlighted in this review article.

Management of a rare complication of endovascular treatment of direct carotid cavernous fistula

A 30-year-old woman with direct carotid cavernous fistula underwent endovascular treatment with detachable balloons via a transarterial route. The patient returned with diplopia 1 year after therapy. On cranial MR imaging, one of the balloons was detected in the proximal portion of the superior ophthalmic vein and was deflated percutaneously with a 22-gauge Chiba needle under CT guidance. The patient's symptoms resolved after balloon deflation. This case report presents a unique complication of endovascular treatment of direct carotid cavernous fistula and its management.

Risk factors for severe hemorrhagic cystitis following BMT

Hemorrhagic cystitis (HC) is a common toxicity of preparative regimens for bone marrow transplantation (BMT). Severe HC often requires prolonged and expensive hospitalization, and occasionally can result in death. To investigate the risk factors for severe HC, we conducted a retrospective study among 1908 patients who received BMTs at the University of Minnesota during 1974 to 1993. A previous report from our institution reported on 977 of these patients. We identified all patients with genitourinary complication within 100 days post-BMT from the BMT database. Medical charts for these patients were reviewed to determine whether the patient had HC and also the grade of HC. A total of 208 HC cases were identified during the study period. Of them, 92 patients had severe HC, an incidence of 5% (95% CI = 4-6%). We found that grade II-IV graft-versus-host disease (RR = 2.56; 95% CI = 1.43-4.56), use of busulfan (RR = 2.69; 95% CI = 1.35-5.35), and age at transplant (RR = 2.20; 95% CI = 1.27-3.81, for age of 10-30 compared to age of 0-9) were related to an increased risk of HC. In contrast, transplant year was inversely associated with the risk of HC (trend test, P < 0.01). We did not find any significant difference in HC with the use of prophylactic Mesna.

Splenic hemangioma with thrombocytopenia in a newborn

The case report of a newborn infant with a splenic hemangioendothelioma with the life-threatening complications of thrombocytopenia, anemia, and disseminated intravascular coagulation is presented together with a review of the literature. Removal of the tumor via splenectomy, despite the known risk of subsequent overwhelming sepsis due to encapsulated organisms in the young child, is the treatment of choice for splenic hemangiomas complicated by thrombocytopenia. The use of enhanced CT with delayed filling is a diagnostic tool in the workup of suspected hemangiomatous lesions.