[Traumatic lesions of the brachial plexus. Evaluation of 144 cases studied using direct cervical myelography and non-ionic contrast media]

The authors report their experience in 144 patients with traumatic brachial plexus injury who underwent Direct Cervical Myelography (DCM). Sometimes the diagnostic investigation was completed by CT. Various myelographic patterns are described: pseudomeningocele, missing sheet of the root, scarring lesions. In 9 cases only, myelography was not sufficient to provide a complete diagnosis. The examination showed all plexus roots lacerated in 14 patients, a monoradicular lesion in 75 cases, and no lesion in 26 cases. Twenty-one out of the 26 negative cases were confirmed during surgery, while in 2 patients an intraspinal injury was found, which had not been detected due to the presence of scars. Scars often compress healthy roots, and may mask intraspinal injuries. In such cases, and when the spinal cord stretches towards the side of the lesion, Myelo-CT can be useful. DCM proved to be an extremely sensitive and specific method, which can be used as a first-choice radiological procedure in the study of traumatic injuries of the brachial plexus.

Results of combined surgical and medical therapy in patients with prolactin-secreting pituitary macroadenomas

To assess the long term effectiveness of combined sequential surgical and medical therapy in the management of prolactin-secreting pituitary macroadenomas, we followed 21 patients for 46 +/- 6 months (mean +/- SE) after diagnosis (range, 12 to 96 months). All patients underwent operation. Six were also treated with bromocriptine, 7.5 mg/day immediately after operation. A group of 15 patients with tumor sizes similar to those of the first group was followed without medical therapy until signs of regrowth of the neoplasia were evident. No patient of the combined therapy group experienced a recurrence of the disease. On the other hand, only 2 patients of the second group were recurrence-free at the end of follow-up. In the other 13 cases, adjunctive therapy had to be established for clinical and radiological evidence of tumor recurrence 26 +/- 7 months after operation. We conclude that combined sequential surgical and medical therapy may be useful in the management of macroprolactinomas. Our hypothesis must be confirmed by studies that compare patients treated with operation plus bromocriptine with patients treated with bromocriptine alone.

Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma (JNA)

Nineteen patients with juvenile nasopharyngeal angiofibroma (JNA) were surgically treated with different techniques from January 1968 through December 1985. Two patients had undergone a previous operation at another hospital; all patients were males (mean age 15.4), and the most common symptom was nasal obstruction (84.2%). Lateral extension into the pterygomaxillary fossa occurred in 14 patients (73.6%), and 2 also had intracranial invasion (10.5%). In five cases, the tumor's cytosol was analyzed for hormonal receptors. Negative values for estrogen and progesterone receptors were obtained, although the content of dehydrotestosterone receptors was highly positive. These results tend to support the hypothesis of JNA's androgen-dependence. The authors emphasize the need of a preoperative staging classification based on clinicoradiological data in selecting the most adequate surgical approach. Tumors with lateral extension into the pterygomaxillary fossa can be easily removed through a midface degloving; large involvement of the infratemporal fossa requires, also, a transzygomatic dissection. In JNAs with intracranial extension a combined intracranial-extracranial approach is advisable.

Lower cranial nerve palsy produced by internal carotid artery dilatation. Report of two cases

We report two cases of lower cranial nerve palsies (XII in case 1, IX-X-XII in case 2) associated with abnormalities of the internal carotid artery at the base of the skull. In case 1 a limited dissection of the carotid wall produced both paresis of the hypoglossal nerve and Horners syndrome by compression of the nerve trunk against the base of the skull and stretching of the periarterial sympathetic fibres respectively. In case 2 we speculate that a narrow angled kinking of the internal carotid artery may have damaged cranial nerves IX, X and XII by interfering with the blood supply to the nerve trunks. In both cases the outcome was favorable with almost complete regression of the initial symptoms. We conclude that the association between lower cranial nerve disturbances and internal carotid artery abnormalities is probably more common than was thought. We suggest that the pathogenesis of the damage to the cranial nerves may differ from one case to the next.

Occurrence of lymphocyte proliferative response to thyroglobulin and antithyroglobulin antibodies in normal individuals: lack of correlation with HLA

Peripheral mononuclear cells (MNC) of patients with autoimmune thyroid disease have been shown to proliferate when cultured with human thyroglobulin (hTg). In addition, such a phenomenon is apparent in a certain number of healthy individuals. In this study we have attempted to correlate hTg-induced MNC proliferation, occurrence of anti-hTg autoantibodies and HLA phenotype (including Class II DR and DQ loci) in a population of HLA-typed normal blood donors. Fourteen out of 56 subjects showed a significant MNC proliferation to hTg. Three of them had anti-hTg autoantibodies in the serum, while none of the hTg-unresponsive subjects showed such antibodies. No correlation with HLA phenotype (including Class II DR5 specificity, referred as associated with Hashimoto's thyroiditis, and DQ alleles) was observed.

The immunological events leading to the "in vitro" response to PPD

In normal individuals the 5/9 monoclonal antibody (5/9 MAb) recognizes a T-cell fraction that includes all T lymphocytes with inducer activities. Here, circulating 5/9+ and 5/9- T lymphocytes were isolated from tuberculim skin-positive subjects and the proliferative response induced by PPD was investigated. The results show that the total PPD-induced lymphocyte DNA synthesis is confined to the 5/9+ T cell fraction. PPD was unable to induce a direct or indirect (through the 5/9+ cells) proliferation of T8+ cells. Whether 5/9 antigen, expressed on the PPD responsive T-cell subset, is involved in PPD-induced cell proliferation, was also analyzed. No significant effect was observed adding 5/9 MAb, whereas complete inhibition of antigen-induced blastogenesis was observed upon addition of a MAb (D1.12) directed to common determinants of Ia antigens. The supernatant fluids of 5/9+ and 5/9- cells stimulated with PPD were studied for the presence of IL-2 and IFN-gamma. Production of both these lymphokines was detected in the 5/9+ T-cell supernatants, whereas neither IL-2 or IFN-gamma were found in supernatants of 5/9- cells. In addition, preliminary experiments suggested that only the supernatants of PPD-stimulated 5/9+ T cells were able to activate a macrophage cell line, inducing a remarkable release of hydrogen peroxide. These results indicate that the lymphocyte responsiveness to PPD is confined in a small T cell fraction, expressing the 5/9 antigen; only these T cells are able to release soluble factors (i.e., IL-2 and IFN-gamma); those or other soluble factor(s) produced in PPD-stimulated cultures seem able to activate the macrophages.

Autologous mixed lymphocyte reaction in Graves' disease: relationship to clinical status

The autologous mixed lymphocyte reaction (AMLR), i.e. the ability of T lymphocytes to proliferate when cultured with autologous non-T cell fractions, is an 'in vitro' phenomenon showing immunological memory and specificity, probably related to the cooperation ability of immunocompetent cells. We have evaluated AMLR in 27 patients with Graves' disease of varying clinical status (untreated and treated with antithyroid drugs, surgery or 131I). The results obtained show: Impaired AMLR in untreated patients (as in other autoimmune diseases). Significantly higher AMLR in cured patients, and that AMLR in cured patients varies with the treatment (higher after surgery or radioiodine than after medical treatment). These results are consistent with the hypothesis of a functional defect of T cells in Graves' disease, which improves when clinical remission is achieved.

Moyamoya syndrome in only one of two identical twins. Case report

The authors describe moyamoya syndrome in only one of two identical twins. The clinical and angiographic data suggest that it may be an acquired form, but the cause of the pathology remains obscure.

Critical evaluation of a new water soluble contrast medium (Iopamidolo) in cervical myelograms

The Authors report the preliminary results in 96 cervical myelograms performed by percutaneous subarachnoid injection at the level C1-C2 of a new water soluble contrast medium (Iopamidolo*). Compared to other water soluble contrast media Iopamidolo offers some advantages: (1) it is a time stable solution ready for immediate use; (2) it gives an ideal density for the study of the cervical spinal canal; (3) it provides high quality radiograms suitable for magnification of anatomical details which give a more accurate surgical diagnosis; (4) it is well tolerated without significant sequelae; no delayed complications were reported up to 15 months. This contrast medium gives valuable results also in myelograms performed by lumbar route.

True aneurysm of the middle meningeal artery. Case report

We report the case of a true aneurysm of the middle meningeal artery (MMA) associated with no other pathological findings. After a review of the literature, we emphasize that this case is not associated either with skull traumas, with vascular hypertension or with Paget's disease of the skull. Histological examination and neuroradiological findings confirm the suspicion that this is a case of true aneurysm of the middle meningeal artery.

[Diazoxide test in the diagnosis of arterial hypertension: modifications in the levels of renin and aldosterone in blood of patients with various restrains of the renal function]

The AA. have applied the diazoxide test for the screening of primary hiperaldosteronism to 22 nephropatic patients suffering from hypertension and with different degrees of renal function. In 22 patients an increase in PRA and aldosterone values always followed the diazoxide infusion. Only one patient, likely suffering from primary aldosteronism, showed no increase in PRA and aldosterone values. The diazoxide infusion had no influence on renal, pancreatic and cardiovascular function. Therefore, this can be considered as a valid test easy to be performed in a short time, also in nephropatic patients who are very sensitive to pharmacological noxae.