Temporary Balloon Occlusion Test of the Left Vertebral Artery Using Parenchymography as Tolerance Predictor

Temporary balloon occlusion is used as tolerance predictor in patients undergoing vascular occlusion with the aid of clinical assessment during a 30–40 minute temporary occlusion. Several other techniques have been used to help predict each patient's tolerance. Digital cerebral parenchymography (DCP) was originally described to improve our analysis of brain perfusion during ischemic events. We report a case using DCP as tolerance predictor in a patient undergoing sacrifice of the left vertebral artery.

Imaging of isolated cerebral mucormycosis. A report of three cases

Mucormycosis is a rare infection in immunosupressed patients caused by fungi from the family Mucoraceae. Three types of disease spread have been described: rhinocerebral, systemic and isolated. Isolated spread is the most uncommon form, usually resulting in death. It has been described in diabetics, immunosupressed patients and intravenous drug abusers. Neuroimaging can aid the diagnosis of this entity, but biopsy remains the only reliable method. Imaging findings of Mucormycosis include abscesses and hemorrhagic or ischemic infarcts, usually in the basal ganglia and frontal lobes. Single or multiple lesions have been described as well as meningoencephalitis. Understanding these findings can help to detect the infection in an early stage. We describe three cases of isolated cerebral mucormycosis; all of them were intravenous drug abusers with one patient also being HIV positive.

Percutaneous Treatment of Lumbar Intervertebral Disk Hernias With Radiopaque Gelified Ethanol

STUDY DESIGN

Prospective clinical trial.

OBJECTIVE

Demonstrate the safety and efficacy of gelified ethanol in the percutaneous treatment of lumbar disk hernias.

SUMMARY OF BACKGROUND DATA

After the commercial withdrawal of Chymopapain, the need for new substances to treat intervertebral disk hernias was evident. Good results were obtained with pure ethanol, but this substance was difficult to handle. We decided to use a similar substance mixed with ethylcellulose to increase its viscosity and enhanced with radiopaque material.

METHODS

Two hundred seventy-six consecutive patients sent to be treated of a lumbar intervertebral disk hernia percutaneously were included in this preliminary study and treated with radiopaque gelified ethanol (RGE) and intra-articular steroids. Three groups were set, group A for patients to be treated only with RGE and groups B and C for difficult cases presenting a narrow canal, foraminal hernia, or hiperalgic sleepless hernia, treated with RGE plus another intradiscal technique, automatized percutaneous diskectomy for group B and radiofrequency nucleoplasty for group C.

RESULTS

Very good or good results were obtained in 202 (91.4%) of the 221 patients in group A. Of the 44 patients in group B, 37 patients (84%) presented very good or good results and in 9 (82%) of the 11 patients of group C, we obtained similar results. There was no allergic complication in any of our patients. Short-term follow-up with magnetic resonance showed little or no changes in the intervertebral disk but there was discordance with clinical signs. Long-term follow-up magnetic resonance showed a dramatic reduction in hernia volume.

CONCLUSIONS

This preliminary study shows the efficacy and inocuity of this new substance that could take over the Chymopapain therapeutic field.

Fatal methadone intoxication in a child

Methadone is an opiate used as part of the treatment for heroin abuse; it can be ingested orally. We present the lethal outcome of a 22-month-old child intoxicated after methadone ingestion.

Management of spinal dural arteriovenous fistulae with emphasis on an endovascular approach

Spinal arteriovenous shunts are rare and present at a rate of approximately 1:10 with cerebral arteriovenous shunts. Spinal dural arteriovenous fistulas (SDAVF) are the most common type of spinal vascular malformation in the adult and account for about 60% of all, with a marked male predominance (5:1). Endovascular treatment has gained force as the treatment of choice in recent years. We reviewed the patients sent to our service at Clinica del Rosario in Madrid and Hospital General de Cataluña in Barcelona between January 1991 and December 2005 with a diagnosis of SDAVF made clinically or by imaging for possible endovascular treatment. Location, presenting symptoms, and clinical outcome according to treatment were analyzed. A total of 104 patients were diagnosed and treated for a SDAVF, 85 were men and 19 women aged between 23 and 79 years (average 58). Seventy-six were treated with embolization alone (73%), 21 with a combination of endovascular therapy and surgery (20.1%) and seven patients had surgery alone (6.7%). Of the embolization group, 62 patients were cured (81.5%), 11 improved (14.4%) and three (3.9%) worsened. Of the group with combined therapy, 13 (61.9%) were cured, five (23.8%) improved and three (14.2%) worsened. Among the surgery group, four (57.2%) were cured and three (42.8%) worsened. Endovascular approach with liquid adhesive is gaining more acceptance as the treatment of choice for SDAVF if the conditions allow a super selective catheterization of the shunt. These patients benefit most when diagnosis is made early in the course of the pathology and have a better chance of a complete remission of symptoms.

Neuroimaging in drug and substance abuse part I: cocaine, cannabis, and ecstasy

Multiple neurological complications of cocaine abuse have been described including both ischemic and hemorrhagic cerebrovascular events, atrophy in the case of chronic abuse, and an increase in incidence of congenital malformations in the setting of maternal use. The abuse of cannabis may cause a number of neurovascular changes that, in turn, may result in ischemic events, however, a direct connection between these has not been fully established. The use of MDMA (ecstasy), a popular recreational drug, has been related to ischemic and hemorrhagic cerebrovascular events, as well as atrophy. Neuroimaging studies are vital in the assessment of the extent of neurologic damage in these patients.

Neuroimaging in drug and substance abuse part II: opioids and solvents

The central nervous system is one of the primary targets for the detrimental effects of drugs of abuse. Diagnostic imaging, especially MRI, plays an important role in the detection of complications associated with drug abuse. We present the imaging findings associated with the abuse of opioids and other morphine derivatives, as well, as solvents. Of the morphine derivatives, heroin is the most commonly abused. Several CNS pathologic effects have been described in association with its abuse. These include neurovascular complications such as microvascular ischemic changes or ischemic stroke. A rare form of leukoencephalopathy has been described in those abusers who inhale heroin vapors. Other neurologic complications include atrophy and various infectious processes. Solvent inhalation is a common practice among adolescents and young adults secondary to its ease of access and low cost. The most important component of industrial solvents is toluene. Complications of toluene abuse may be either acute, showing no neuroradiological changes, or chronic, characterized by cerebral and cerebellar demyelination as well as atrophy.

PET and SPECT in drug and substance abuse

The use of imaging in the evaluation of the brain under the influence of drugs has evolved into a functional assessment of its processes. It has been shown that SPECT and PET imaging studies demonstrate selected areas that are affected by multiple drugs among substance abusers. This paper illustrates examples of different drugs and how their effect on the brain may be portrayed by imaging applications. The developing "road maps" that we have obtained possess multidimensional applications. They can be useful to confirm specific diseases, clarify diagnosis wherein the clinical picture is not observed, aid in the development of new treatment evaluations and also provide researchers a better insight in the detection and functionality of dementia and specific mental illnesses processes.

Musculoskeletal infection imaging: Past, present, and future

Imaging plays a key role in the evaluation of patients with known or suspected musculoskeletal infection. Although conventional radiograph still remains as the initial imaging approach, it has low sensitivity and specificity in the setting of acute infection. Magnetic resonance is highly sensitive for the detection of acute osteomyelitis and septic arthritis. Computed tomography is usually reserved for guided interventional procedures (eg, aspiration or drainage) and for evaluation of sinus tracts in chronic infections. Ultrasound is useful for fluid detection in joints and soft tissues but limited in bone assessment. Nuclear medicine, with the different radiotracers currently available, is highly sensitive for the diagnosis of acute osteomyelitis. Newer radiotracers are being developed that promise high sensitivity and specificity for the detection of these pathologies.

Identifying and reducing errors with surgical simulation

The major determinant of a patient's safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills-which are at the core of the profession-are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and "near misses". Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.

Identifying and reducing errors with surgical simulation

The major determinant of a patient's safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills-which are at the core of the profession-are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and "near misses". Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.

Successive clutches induced by surgical excision of post-ovulatory oocytes in the lizard Cnemidophorus uniparens

19 animals had eggs excised from the oviducts soon after ovulation. Number of clutches was nearly tripled in excised animals as compared to controls. An influence of eggs in the oviduct on number of clutches is suggested and may indicate a neuronal link between oviduct and hypothalamus.