Basic Imaging of Skull Base Trauma

Skull base fractures extend through the floor of the anterior, middle, or posterior cranial fossa. They are frequently associated with complex facial fractures and serious complications such as cranial nerve or vascular injury, cerebrospinal fluid leak, or meningitis. Several distinct patterns of skull base fractures have been recognized, each of them associated with different complications. Recognition of, often subtle, skull base fracture is essential to prevent or allow early treatment of these serious complications.

Delayed diffusion-weighted MR abnormality in a patient with an extensive acute cerebral hypoxic injury: A case report

Diffusion-weighted (DW) MR imaging usually identifies acute cerebral infarction injury in symptomatic patients. We report a patient with severe hypoxic brain injury following suicide attempt by hanging, but with normal DW MR imaging 5–6 h after the event. Follow-up DW MR imaging 3 days after the event, and subsequent autopsy, revealed extensive cerebral anoxic injury.

Imaging Characteristics of Olfactory Neuroblastoma (Esthesioneuroblastoma)

This presentation outlines the clinical and imaging characteristics of esthesioneuroblastoma.

Combined Balloon Test Occlusion and SPECT Analysis for Carotid Sacrifice: Angiographic Predictors for Success or Failure?

Objectives To evaluate angiographic patterns that may predict the success or failure of carotid artery balloon test occlusion (BTO) and single-photon emission computed tomography (SPECT) analysis for carotid sacrifice. Study Design This is a retrospective nonrandomized study. Study Setting Conducted at the University of California Davis Medical Center, Sacramento, California. Patients A total of 31 patients, ranging from 24 to 83 years of age, with a mean age of 61 years (22 men, 9 women) with head and neck cancer (26 patients), malignant glomus tumor (1 patient) or giant carotid aneurysms (4 patients) as possible candidates for surgical carotid artery sacrifice were evaluated from September 2005 to September 2012. Methods All patients underwent unilateral internal carotid artery balloon test occlusion with SPECT analysis (20 mCi technetium 99m-hexamethyl propyleneamine oxime [HMPAO]) imaging before and during carotid occlusion. Carotid angiography with carotid cross-compression (manual compression of the cervical artery contralateral to the side of contrast injection) was used to analyze filling through the anterior communicating artery to the contralateral hemisphere. Intervention The balloon occlusion was terminated in two patients because of deterioration of the neurologic exam. Main Outcome Measures All patients who passed the neurologic examination during BTO and also passed the SPECT occlusive study underwent successful carotid sacrifice without neurologic sequelae. Patients failing the occlusive neurologic examination and/or the SPECT study elected chemoradiation, with the exception of one patient who underwent a successful carotid bypass graft and carotid resection. Results The success of carotid sacrifice in patients passing both the occlusive test and the SPECT analysis for carotid sacrifice was 100%. Three patients failed both the BTO and the SPECT, with two demonstrating no anterior circulation cross-fill, but one showed some cross-fill. Six additional patients passed the BTO but failed the SPECT, with poor cross-fill in five patients. In addition, three patients who had excellent cross-fill through the anterior communicating artery to the contralateral hemisphere failed the SPECT examination in two cases and failed both tests in another case.

Lateral Pterygoid Fracture Can Predict a Mandible Fracture

Objective: Isolated lateral pterygoid plate fractures on head CT imaging can serendipitously be associated with mandible fractures on subsequent maxillofacial imaging. Our objective is to understand the mechanism and to establish a protocol for the radiographic evaluation for this phenomenon.

Method: We performed a retrospective case series of 7 maxillofacial trauma patients with evidence of isolated lateral pterygoid fractures noted on CT images between 2006 and 2012 at our tertiary care institution. Subsequent maxillofacial CT images with coronal, axial, and sagittal views allowed for complete evaluation of maxillofacial trauma.

Results: Seven patients between 2006 and 2012 who sustained facial trauma were found to have isolated lateral pterygoid plate fractures. Subsequent evaluation via maxillofacial CT showed associated mandible fractures. All the patients were men with an average age of 37 years. Seven patients had an ipsilateral subcondylar fracture, 2 had a symphyseal fracture, 2 had a body fracture, and 1 had a coronoid fracture.

Conclusion: Isolated lateral pterygoid fractures noted on head CTs are suggestive of associated mandibular fractures. The proposed mechanism is an acute force on the mandible that is traduced through the pterygoid muscles. A dedicated maxillofacial CT may reveal an associated mandibular fracture even in the setting of negative clinical exams.

Imaging findings of rhinocerebral mucormycosis

BACKGROUND AND OBJECTIVES

The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis of rhinocerebral mucormycosis.

METHODS

We retrospectively evaluated the imaging and clinical data of four males and one female, 3 to 72 years old, with rhinocerebral mucormycosis.

RESULTS

All the patients presented with sinusitis and ophthalmological symptoms. Most of the patients (80%) had isointense lesions relative to brain in T1-weighted images. The signal intensity in T2-weighted images was more variable, with only one (20%) patient showing hyperintensity. A pattern of anatomic involvement affecting the nasal cavity, maxillary sinus, orbit, and ethmoid cells was consistently observed in all five patients (100%). Our series demonstrated a mortality rate of 60%.

CONCLUSION

Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis. In the context of immunosupression, a pattern of nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Multiplanar magnetic resonance imaging shows anatomic involvement, helping in surgery planning. However, the prognosis is grave despite radical surgery and antifungals.

Endovascular treatment of penetrating traumatic injuries of the extracranial carotid artery

PURPOSE

To describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the extracranial carotid artery.

MATERIALS AND METHODS

The clinical and angiographic features of 36 traumatic injuries of the carotid artery during a 12-year period were reviewed. There were 35 male patients (97.2%) and 1 female patient (2.8%) with an average age of 28.8 years (range 13-60 years). Of the 36 lesions of the carotid artery, 29 (80.6%) were the result of gunshot injury, and 7 (19.4%) were secondary to stab wounds. In 24 (66.7%) instances, the injury resulted in a pseudoaneurysm; in 7 (19.4%), in an arteriovenous fistula (AVF); in 4 (11.1%), in a dissection; and in 1 (2.8%), in inactive bleeding. All patients were treated with an endovascular approach using different techniques (balloon occlusion, embolization, or stent deployment).

RESULTS

Endovascular therapy resulted in documented lesion occlusion in 34 (94.4%) patients. Two patients declined any follow-up postprocedural imaging; however, they have remained asymptomatic. Clinical improvement was documented in 35 (97.2%) patients, and there was one procedure-related complication with fatal consequences.

CONCLUSIONS

In this series, endovascular techniques were an effective method of treatment. It was possible to use different endovascular reconstructive techniques or parent artery occlusion depending on the degree of vessel damage, with resolution of clinical symptoms and avoidance of surgery in most cases.

Pediatric lipoblastoma in the head and neck: a systematic review of 48 reported cases

BACKGROUND

Lipoblastoma is an exceedingly rare cause of pediatric head and neck masses. There have been 47 cases previously reported in the English literature. We present an additional case and review of the available literature on this rare neoplasm.

OBJECTIVE

To review and assess the current published literature regarding the efficacy of preserving neurovascular structures in the surgical management of pediatric lipoblastoma.

METHODS

Literature analysis of case reports was performed. MEDLINE was searched for the terms "neonatal lipoblastoma", "lipoblastomatosis", and "benign lipoblastoma". Results in the English literature were mined for relevant clinical data when available. The citations of case reviews found were searched to find additional cases.

RESULTS

Including our new case, a total of 48 cases of head and neck lipoblastoma have been reported in the English literature within 23 manuscripts. Four manuscripts presented cases series (Evidence Based Medicine Level 4) and 19 were case reports (Level 5). The median sample size was 1 (range 1-4). For those 14 articles (N=23 cases) reporting follow-up, the median follow-up duration was 22 months. Male to female ratio was 2.1:1 with an average age at presentation of 2.1 years (range: newborn to 12 years). Lesions ranged from 3 to 12 cm in longest diameter. Recurrence was seen in 27% of patients in which there was at least 1-year follow-up. The most common presenting symptoms were painless enlarging neck mass (53%, 17/32) and respiratory distress (12%, 4/32). An exact binomial sign test indicated that most authors recommend conservative complete excision with preservation of vital structures with 10 of 11 authors giving a stance supporting conservative surgical resection, p=.012.

CONCLUSIONS

Our findings suggest that although total excision is ideal and curative, subtotal resection may be a viable treatment alternative for lipoblastoma of the head and neck. This tumor presents a clinical challenge and should be considered in infants presenting with a cervical mass. It is difficult to differentiate from the much more common lymphangioma on clinical and radiological examination. Additionally, the potential for rapid growth and adhesion to neurovascular tissue makes surgical resection arduous. Nonetheless, recurrence rates for head and neck lipoblastomas are similar to those rates observed elsewhere in the body.

Leptomeningeal cyst of the orbital roof in an adult: case report and literature review

OBJECTIVE

To present the case of a leptomeningeal cyst involving the orbital roof in an adult.

DESIGN

Case report and literature review.

SETTING

Tertiary referral center.

SUMMARY

A 47-year-old female with a remote history of a skull fracture at 3 years of age presented with increasing headaches and retro-orbital pain. A computed tomogram and magnetic resonance image revealed a leptomeningeal cyst of the orbital roof.

RESULTS

Only one previous leptomeningeal cyst of the orbital roof has been reported in an adult. Surgical excision of the lesion was performed and follow-up imaging 18 months after the operation revealed no evidence of recurrence.

CONCLUSION

Although extremely rare, adult patients can develop growing skull fractures or leptomeningeal cysts of the orbital roof. Such lesions should be included in the differential diagnosis when a patient presents with orbital pain or exophthalmos and a history of head trauma as a child.

Endovascular treatment of traumatic injuries of the vertebral artery

BACKGROUND AND PURPOSE

There are a few reports regarding the treatment of traumatic vertebral arteriovenous fistulas and pseudoaneurysms. Our aim was to describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the vertebral artery.

MATERIALS AND METHODS

The clinical and angiographic features of 18 traumatic injuries of the vertebral artery during an 8-year period were reviewed. There were 14 male (78%) and 4 female patients (22%). The average age was 28 years (range, 11-49 years). Of the 18 lesions of the vertebral artery, 17 (95%) were the result of penetrating trauma (gunshot or stab wound injury) and 1 (5%) was iatrogenic (jugular vein catheter). In 16 (89%) instances, the injury resulted in an arteriovenous fistula, and in the other 2 (11%), in a pseudoaneurysm. All patients were treated with an endovascular approach by using different techniques (balloon occlusion, coil embolization, and/or stent deployment).

RESULTS

Endovascular therapy resulted in immediate lesion total occlusion in 16 (89%) patients. Delayed total occlusion was demonstrated angiographically during follow-up in the 2 remaining patients. Clinical improvement was documented in all patients, and there were no clinically symptomatic complications.

CONCLUSION

In this small series, endovascular techniques were a safe and effective method of treatment and were not associated with significant morbidity or mortality.

The association of brainstem lesions with migraine-like headache: an imaging study of multiple sclerosis

OBJECTIVE

To determine if the prevalence of migraine-like headache in patients with multiple sclerosis (MS) is associated with plaques in the brainstem or in other locations.

BACKGROUND

There is increasing evidence to suggest that periaqueductal gray matter (PAG) plays a role in the pathophysiology of migraine headache. There are a few clinical case studies and some experimental evidence in support of this observation.

METHODS

The study population of patients with demyelinating disease was identified by accessing the Department of Radiology magnetic resonance imaging (MRI) database accumulated between the years of December 1992 and June 2002. A total of 4369 MRI scan reports were available for review from that time period. Out of this, 1533 studies were reported to have possible demyelinating lesions. Medical records of these patients were reviewed to confirm the diagnosis of MS and also to document the headache complaints, if any. Two hundred and seventy-seven patients were identified with definite MS. A questionnaire was mailed to these patients to obtain additional details regarding MS and headache. The questionnaire response rate was 61% (169 of 277). This data were added to the information previously obtained from the medical records. The MRI films of each patient were examined, documenting location of the plaque, rather than the actual number. MRI and clinical data were kept separate until the final analysis. The International Headache Society criteria were used to classify headache types.

RESULTS

There were 207 female and 70 male patients available for analysis. Sixty-six percent (182 of 277) of patients were diagnosed with remitting-relapsing MS, 17% (47 of 277) with primary progressive MS, and 17% (48 of 277) with secondary progressive MS. Overall, 55.6% (154 of 277) of patients had a complaint of headache. Of these patients, 61.7% (95 of 154) met criteria for migraine-like headache, 25.3% (39 of 154) met criteria for tension-type headache, and 13% (20 of 154) had features of migraine and tension-type headache. MS patients with a plaque within the midbrain/periaqueductal gray matter areas had a four-fold increase in migraine-like headaches (odds ratio 3.91, 95% confidence interval 2.01 to 7.32; P < .0001), a 2.5-fold increase in tension-type headaches (odds ratio 2.58, 95% confidence interval 1.13 to 5.85; P= .02), and a 2.7-fold increase in combination of migraine and tension-type headaches (odds ratio 2.77, 95% confidence interval 0.98 to 7.82; P= .05) when compared to MS patients without a midbrain/periaqueductal gray matter lesion. Although not statistically significant, MS patients with three or more lesion locations were found to be approximately two times more likely to have migraine-like headaches compared to MS patients with 0 to 2 locations (3 to 5: odds ratio 2.47, 95% confidence interval 0.90 to 6.84; 6 to 8 locations: 1.82, 0.64 to 5.17; > or =9 locations: 2.41, 0.63 to 9.13). A linear trend was also observed between numbers of lesion locations and migraine-like headaches (P= .02).

CONCLUSION

The results of this study indicate that the presence of a midbrain plaque in patients with MS is associated with an increased likelihood of headache with migraine characteristics. (Headache 2005;45:670-677).

The vertebral body fracture in osteoporosis: restoration of height using percutaneous vertebroplasty

BACKGROUND AND PURPOSE

Percutaneous vertebroplasty is an effective tool for the relief of pain caused by osteoporotic spine fractures. Our purpose is to evaluate this technique and its effectiveness in restoring the height of such fractures.

METHODS

Forty osteoporotic vertebral body fractures in 30 consecutive patients (24 female, six males; mean age, 70 years) were analyzed retrospectively, before and after percutaneous vertebroplasty, for changes in vertebral body height, kyphosis angle, and wedge angle. The ages of the fractures range from 1 to 5 months.

RESULTS

Percutaneous vertebroplasty improved the pretreatment height of compression fractures in these patients by a mean of 47.6% (P < .001), with only 15% showing no improvement. These figures compare favorably with published results for kyphoplasty (47% mean improvement in height in 70% of fractures; no improvement in 30% of fractures). In addition, we achieved a mean improvement in kyphosis angle of 6 degrees and an improvement in the wedge angle of 3.5 degrees (as compared with published results for kyphoplasty of 7.4 and 4.3 degrees , respectively; P < .001).

CONCLUSION

Percutaneous vertebroplasty should be viewed not only as a pain-relieving procedure, but also an effective method for improving vertebral body height, kyphosis angle, and wedge angle.

Delayed diffusion-weighted MR abnormality in a patient with an extensive acute cerebral hypoxic injury

Diffusion-weighted (DW) MR imaging usually identifies acute cerebral infarction injury in symptomatic patients. We report a patient with severe hypoxic brain injury following suicide attempt by hanging, but with normal DW MR imaging 5-6 h after the event. Follow-up DW MR imaging 3 days after the event, and subsequent autopsy, revealed extensive cerebral anoxic injury.

Isolated sulfite oxidase deficiency: MR imaging features

Isolated sulfite oxidase deficiency is a rare autosomal inherited disorder of the normal degradation of sulfur-containing amino acids. Premature death in infancy secondary to severe neurologic deterioration is the usual outcome. This article provides an analysis, in temporal form, of brain imaging findings in this disorder.

One-year follow-up evaluation of magnetic resonance imaging of the brain in dogs with pituitary-dependent hyperadrenocorticism

OBJECTIVE

To evaluate magnetic resonance imaging (MRI) brain scans of dogs with pituitary-dependent hyperadrenocorticism (PDH) and no signs of CNS dysfunction 1 year after diagnosis and initial MRI.

DESIGN

Prospective study of surviving dogs from a previous study.

ANIMALS

13 dogs underwent MRI of the brain at the time that PDH was diagnosed and prior to treatment. At that time, none of the dogs had clinical signs suggestive of an intracranial mass. Approximately 1 year after diagnosis and MRI, the brain was again evaluated by MRI.

RESULTS

On the initial MRI scan, 5 of the 13 dogs had normal findings, and 8 had evidence of a mass (tumor) in the area of the pituitary gland. Of the 5 dogs that had no visible pituitary mass on the initial MRI scan, 3 had a normal MRI brain scan 1 year later. Of the 5 dogs that had no visible pituitary mass on initial MRI scan, 2 had a visible pituitary mass at 1 year. The 8 dogs that had a visible mass on the initial MRI brain scan had easily identified pituitary masses on the second MRI scan. Of these 8 dogs, 4 had no apparent change in pituitary mass size, and 4 had obvious increase in vertical height of the pituitary mass. Of the 4 dogs, 2 developed signs of neurologic dysfunction within 1 year after diagnosis of PDH, presumably attributable to that mass. Of the 13 dogs, 12 were treated with mitotane soon after completion of the initial MRI scan. Sensitivity to mitotane and initial pituitary mass size or growth were not correlated. Of the 13 dogs evaluated initially and 1 year after diagnosis, 10 had pituitary masses identified on MRI brain scans.

CLINICAL IMPLICATIONS

The incidence of visible pituitary masses among dogs with PDH at the time of or within a year of diagnosis was > 75%. In 2 dogs, signs of CNS dysfunction developed within 1 year of PDH diagnosis when pituitary masses were > or = 10 mm.

Magnetic resonance imaging of the brain in dogs with recently diagnosed but untreated pituitary-dependent hyperadrenocorticism

Magnetic resonance imaging was used to determine the prevalence of visible pituitary masses in 21 dogs with recently diagnosed and untreated pituitary-dependent hyperadrenocorticism. All dogs had clinical signs and routine database values (CBC, serum biochemical panel, and urinalysis) consistent with a diagnosis of hyperadrenocorticism, and none had clinical signs suggestive of an intracranial mass. Each dog had plasma cortisol concentrations after adrenocorticotropic hormone administration or low-dose dexamethasone administration consistent with hyperadrenocorticism. Pituitary-dependent hyperadrenocorticism was confirmed by the finding of 2 equal-size adrenal glands on abdominal ultrasonography and by results of plasma endogenous adrenocorticotropic hormone concentration and high-dose dexamethasone suppression testing. Sagittal and transverse T1-weighted magnetic resonance images of the brain were obtained before and after IV administration of gadopentenate dimeglumine. Eleven dogs had visible masses, ranging in size from 4 to 12 mm at greatest vertical height. Mean age and body weight of dogs with a visible pituitary mass was not significantly different from dogs without a visible mass. There was no significant difference in endocrine test results when comparing dogs with a visible pituitary mass to dogs without. The prevalence of visible pituitary masses in dogs with pituitary-dependent hyperadrenocorticism was greater than suggested by the prevalence of clinical neurologic signs.

Magnetic resonance imaging for diagnosis of pituitary macrotumors in dogs

The value of magnetic resonance imaging (MRI) for the evaluation of dogs with pituitary-dependent hyperadrenocorticism (PDH) and CNS signs was assessed. Magnetic resonance imaging of the brain was performed in 13 dogs with PDH and neurologic signs. The diagnosis of PDH was made on the basis of results of adrenocortical function tests and abdominal ultrasonography, in conjunction with appropriate history, clinical signs, and clinicopathologic alterations. Eight dogs had been treated with the adrenocorticolytic agent, mitotane, for 1 to 30 months before the development of neurologic signs. Prior to MRI, each dog had progressive neurologic signs that could not be attributed to hypocortisolism or mitotane toxicosis. The neurologic signs most frequently detected were disorientation and ataxia. Mean age of dogs at the time neurologic signs developed was 9.5 years. Sex predilection was not detected; however, most were large-breed dogs, with 11 of the 13 dogs weighing more than 20 kg. A large mass in the pituitary gland, suprasellar region, or both was easily identified on the magnetic resonance images of each dog. The masses ranged from 8 to 24 mm in size. Expansion of tumors into the suprasellar region and compression of structures adjacent to the pituitary gland were readily detected by MRI. Contrast enhancement did not improve tumor identification, but did enable better delineation between tumor and surrounding structures. After the diagnosis of a macrotumor was made by MRI, radiotherapy was initiated in 9 dogs and was successfully completed in 6. Three dogs had a relapse of neurologic signs 8, 11, and 26 months after radiotherapy was completed.(ABSTRACT TRUNCATED AT 250 WORDS)

Dural and carotid cavernous sinus fistulas. Diagnosis, management, and complications

Carotid cavernous sinus fistulas (CCSFs) are a rare entity occurring as a result of head trauma and also spontaneously. The major threat from these fistulas is loss of vision. The authors reviewed 18 cases of direct and dural CCSFs seen over the last 10 years and compared our results with 553 cases treated in the literature. Seventy-one percent of our patients with direct CCSFs had successful balloon embolization. In the literature, successful closure of direct CCSFs has ranged from 58 to 100%. As experience with embolization techniques broadens, morbidity and mortality is reduced. The clinical features, diagnostic procedures, therapeutic options, and complications of treatment of CCSFs are discussed.

Rupture of inferior thyroid artery aneurysm

We report a case in which rupture of an aneurysm of the inferior thyroid artery caused respiratory arrest. The aneurysm was embolized successfully by an angiographic technique. Published reports of rupture of thyroid artery aneurysms are reviewed.

Long-term delta-9-tetrahydrocannabinol treatment. Computed tomography of the brains of rhesus monkeys

High-resolution computed tomographic (CT) scanning of the brain was performed on three groups of rhesus monkeys for the detection of ventricular or cisternal enlargement. These three groups comprised four age-matched controls that had no prior drug usage--four monkeys receiving short-term (two to ten months) orally administered delta-9-tetrahydrocannabinol (delta 9-THC [now known nonproprietarily as dronabinol] and four monkeys receiving long-term (five years) orally administered delta 9-THC. Our results show a statistically significant enlargement of the frontal horns and the bicaudate distance in the long-term group as compared with the control and less significant enlargement of these areas in the long-term group compared with the short-term group. These findings suggest atrophy of the head of the caudate nucleus and the frontal portion of the brain of rhesus monkeys receiving long-term treatment with delta 9-THC.

Outpatient low-dose computed tomography metrizamide myelography and evaluation of lumbar disk disease

Outpatient low-dose computed tomography metrizamide myelography (CTMM) for the evaluation of lumbar disk disease is described in 55 patients. Ten individuals (group 1) were studied using 3.5 ml of 150 mg I/ml (525 mg I total) of metrizamide. Forty-five additional patients (group 2) were examined with 5 ml of 110 mg I/ml (550 mg I total) concentration of metrizamide. Group 2 experienced less post-procedure headache (6.6%) and nausea (2.2%) than did group 1 (30% and 10%, respectively). Group 2 demonstrated a lowered rate of headache (p less than .01) and showed a trend to less nausea (p less than .09) than a recently published study describing full-dose lumbar myelography. In addition, CTMM in group 2 produced more uniform mixing of metrizamide than in group 1. Overall, low-dose CTMM increased accuracy and reduced morbidity, patient cost, and inconvenience as compared with routine full-dose lumbar myelography.

Residual myelographic contrast material seen on the chest radiograph

Oily contrast material remaining after myelography may escape through the lumbar needle track and enter the dependent thoracic extradural spaces as droplets and collections in the intercostal spaces. Until these intercostal collections are absorbed, which takes place slowly over a period of one or more years, they can produce densities on the chest radiograph. The authors report 26 such cases representing three different patterns of distribution.

Percutaneous transluminal carotid angioplasty in fibromuscular dysplasia. Case report

A patient with fibromuscular dysplasia (FMD) of the internal carotid artery was treated by balloon percutaneous transluminal angioplasty (PTA). This is the sixth reported case of FMD stenotic disease which was dilated by PTA. All previous cases including the current example were treated successfully with resolution of symptoms. This procedure is associated with a relatively low morbidity and is an alternative method of treatment to operative endarterectomy for this disorder.

The value of computed tomographic metrizamide myelography in the neuroradiological evaluation of the spine

The diagnostic value of plain film metrizamide myelography (PFMM) was compared with computed tomographic metrizamide myelography (CTMM) in a study of 106 individuals who had undergone high-resolution computed tomographic scanning of the spine. CTMM provided more significant information than PFMM in 42 of 106 cases (40%), but showed no advantage over PFMM in 63 of 106 cases (59%). In 19 of the 42 cases (45%), PFMM was useful in directing the CT analysis to the appropriate region of pathology. In one patient, PFMM revealed a mobile herniated disc that had not been visualized with CTMM. In 30 of 106 cases in which plain CT scans of the spine were also obtained, the addition of intrathecal metrizamide demonstrated additional pathology in ten individuals. In general, CTMM was useful in the delineation of a variety of pathologic entities, especially neoplasms and congenital abnormalities. Low-dose CTMM (3 ml of a 150 ml/mg concentration) was performed as an outpatient procedure and found to be a useful adjunct to plain CT in two patients. A schema for the radiological evaluation of pathology of the spine is presented.

Carotid blood flow response to Conray-60: diagnostic implications

The vasoactive effect of the angiographic contrast medium Conray-60 (iothalamate meglumine 60%) on carotid blood flow was studied by the video dilution technique in 26 subjects during routine neuroangiography. After a test series of 1 ml injections of contrast material into the carotid arteries at designated time intervals, an increase in carotid blood flow was found in normal controls at 30 sec, while a significant decrease in flow was observed in patients with atheromatous disease and avascular intracranial masses (p less than 0.01). Test responses in patients with intracranial aneurysm, neoplasm, and granulomatous vasculitis are also reported. The differential effect of contrast material on the cerebral circulation correlates well with several pathologic states of the central nervous system and may be used as a simple test to diagnose and evaluate a variety of vascular disorders.

Carotid blood flow in man determined by video dilution technique: II. Vascular abnormalities

Carotid blood flows were evaluated in 31 individuals with vascular abnormalities using the video dilution technique. In patients with stenoses, angiographically estimated at 70%, blood flow was usually, but not always, measured less than normal. The technique proved to be useful in the evaluation of the efficiency of collateral arterial pathways and in the evaluation of superficial temporal-middle cerebral arterial bypass grafts. It was also helpful in estimating contralateral increase in arterial flows with cross compression techniques for the preoperative evaluation of patients subjected to carotid sacrifice. In a limited number of patients video dilution flows correlated with the degree or proximal arterial spasm and were useful in the preoperative study of these patients. The demonstration of flow abnormalities in patient with seizure disorders may be useful in the medical and surgical management of these individuals.

Assessment of cerebral blood flow in man by video dilution technique: a preliminary report

Video dilution technique (VDT) is currently performed in conjunction with routine cerebral angiography to determine carotid blood flow in humans. Preliminary results indicate that the blood flows (as a percentage of cardial output) of the common, internal, and external carotid arteries are 8.5%, 5.5%, and 3.0%, respectively (SD less than 1%). In contradistinction to previous techniques, VDT provides a safe and highly accurate method of determining carotid blood flow in human subjects. The usefulness of this technique in normal and pathologic states is discussed.

Cranial computed tomography in the diagnosis of symptomatic indirect trauma to the carotid artery

Five patients who were involved in motor vehicle accidents sustained indirect, nonpenetrating carotid artery injuries leading to cerebral infarction. Four patients were conscious when a severe lateralized neurological deficit developed three to 12 hours after injury indicating the presence of a vascular injury and not a mass lesion. In 3 patients with occlusion of the main stem middle cerebral artery, computed tomographic (CT) scans performed between 1 and 7 hours after the onset of the ischemic signs were normal, but all scans performed after 11 or more hours revealed progressive edema in a vascular distribution leading to a midline shift. The fifth patient had a severe diffuse brain injury and no apparent clinical pattern of a posttraumatic vascular complication. Sequential changes on the CT scans similar to those of the other patients led to the proper diagnosis of vascular injury; this was later confirmed by arteriography. Indirect, nonpenetrating injury to the carotid artery should be suspected in the presence of the typical clinical pattern or when serial CT scans show the evolution of progressive edema in a distribution atypical for traumatic contusion.

Classic and contemporary imaging of coccidioidomycosis

Disseminated coccidioidomycosis should be considered as a diagnostic possibility whenever a patient has visited or resides in an endemic coccidioidal area and has a history of fever, skin rash, persistent pulmonary symptoms, bone pain, headache, or confusion. Imaging of this multisystem disease, especially of the lung, bone, and central nervous system, shows various protean manifestations that can simulate many infectious entities. The radiographic, scintigraphic, computed tomographic, or sonographic findings of this disease may be helpful in diagnosis, prognosis, and treatment follow-up in patients with disseminated coccidioidomycosis.

Carotid blood flow in man determined by video dilution technique: 1. Theory, procedure, and normal values

The blood flows in the common, internal, and external carotid arteries were determined as a percentage of the cardiac output by video dilution technique in 20 normal subjects during routine angiography. Nine women and 11 men, ages 19-63 years, displayed a mean flow in the common carotid of 8.5% (SD +/- 0.9%; n = 40); internal carotid, 5.3% (SD +/- 1.0%; n = 24); and external carotid, 3.2% (SD +/- 0.4%; n = 24). Relative flow is calculated by a modification of the Stewart-Hamilton principle. The technique is fast, simple, highly accurate, and avoids the errors connected with previous videodensitometric mean transit time techniques. The method can be used in routine angiography without prolonging the catheterization procedure or adding to the patient's risk or cost.

Cerebral blood flow determination by video dilution technique in a patient with malignant chemodectoma

Cerebral angiography performed on a patient with a preliminary diagnosis of jugular foramen syndrome revealed a highly vascular malignant chemodectoma supplied mainly by the left ascending pharyngeal artery. Blood flow was determined during angiography in the extracranial branches of the carotid arteries by video dilution technique. The decrease of blood flow after partial embolization of the left ascending pharyngeal artery was also quantified. The application and value of video dilution technique in blood flow determination, together with the angiographic findings are discussed.

Diagnostic image evaluation of hydranencephaly and pictorially similar entities, with emphasis on computed tomography

The radiographic evaluation of a spectrum of vascular cerebral damage is presented, ranging from simple porencephaly to the most severe form, classic hydranencephaly. With a combination of clinical materal and computed tomography, it is possible in most cases to arrive at a specific diagnosis of hydranencephaly or severe bilateral porencephaly. Pictorially similar entities, such as massive congenital subdural hematomas or hygromas, alobar holoprosencephaly, massive hydrocephalus, and massive postanoxic or infective encephalopathies, are discussed.

Computed tomography of disseminated coccidiodomycosis

Fifteen cases of disseminated cerebral coccidioidomycosis (DCC) were evaluated by computed tomography (CT). Of the 14 patients with abnormal CT scans, all but 2 showed definite evidence of hydrocephalus. Abnormalities of the basal cisterns were present on non-contrast scans in 8 cases (53%). Ten (67%) demonstrated abnormal contrast enhancement of basal cisterns and other cerebrospinal fluid (CSF) spaces. White-matter lesions were detected in 6 cases (40%). Hydrocephalus usually follows abnormal enhancement of basal cisterns. A consistent relationship between active disease (as diagnosed by CSF complement fixation titers) and contrast enhancement could be demonstrated only in the first weeks of the illness.

Traumatic dislocation of the atlanto-occipital articulation (AOA) with short-term survival. With a radiographic method of measuring the AOA

Three patients with traumatic atlanto-occipital articulation (AOA) dislocation are presented, and an additional 10 well documented cases are reviewed from the literature. Medulla oblongata and/or spinal cord deficits, and evidence of cranial nerve injuries were noted in eight patients. Angiographic evidence of vertebral occlusion or narrowing was demonstrated in four patients. One patient had systemic hypertension, presumably from bilateral traumatic ninth nerve injuries. Five patients ultimately died. A new method of measuring the AOA is introduced.

Cerebral aneurysmal rupture during angiography with confirmation by computed tomography: a review of intra-angiographic aneurysmal rupture

Rupture of a cerebral aneurysm during angiography, with confirmation by computed tomography (CT), is described. A review of 30 additional reported cases demonstrates no unusual profiles, with the exception of the predominance of female patients (71%), and the presence of pre-angiographic arterial hypertension. Experimental and clinical evidence increasingly suggests that intravascular pressures are transiently elevated during cerebral angiography. These changes may be enhanced by increased flow rates of contrast media, smaller diameters of the catheters, and the presence of intracranial arterial spasm, the latter presenting as a very prominent feature in intra-angiographic arterial rupture. However, direct evidence of elevation of the intra-aneurysmal pressure has not been documented, and may have occurred in only a portion of the cases.

Fluid--fluid level in cystic cerebral metastatic melanoma

Two cases of cystic metastatic melanoma are presented. The only reliable computed tomography sign of a true cystic lesion is the presence of an interface, such as between blood and tumor fluid. Differentiation of cystic metastatic melanoma from other cystic lesions of the brain is discussed.