Multiple Cerebral Aneurysms Associated with Atrial Myxoma

Cardiac myxoma is a tumor of mesenchymal origin accounting for half of all primary cardiac neoplasms. Intracranial involvement by atrial myxoma is a rare cause of neurologic deficit. When the myxoma arises in the left atrium, systemic emboli from a cardiac myxoma can lead to infarction, cerebral hemorrhage and aneurysm formation. In the light of the potentially preventable nature of these lesions, the diagnosis of myxomatous aneurysms should be considered in any patient with neurologic symptoms and a history of cardiac myxoma. Because aneurysms are often stable over several years, conservative management with careful clinical and radiological follow-up with MRI and angiography seems sensible. We describe a case in which MR imaging and angiography were used to diagnose multiple cerebral aneurysms caused by left atrial myxoma.

Recurrent Intraventricular Hemorrhages Caused by an AVM Detected by Angiography with Initially Normal Angiogram

Primary intraventricular haemorrhage (PIVH) is an uncommon type of non-traumatic cerebral haemorrhage limited to the ventricular system arising in adults and children, with diverse aetiology and variable course. Vascular malformations account for 34% of PIVH, whereas no cause is found in 21–47%. When a primary intraventricular haemorrhage is detected in a young patient an underlying lesion such as an arteriovenous malformation (AVM) must be ruled out. The diagnosis may be suspected when there is sudden onset of headache, nausea and vomiting with or without a reduced level of consciousness. Nevertheless, even if clinical features suggest the diagnosis of PIVH, cerebral computed tomography (CT) scan is required for confirmation, and magnetic resonance imaging (MRI) and catheter angiography are necessary to establish the aetiology. We describe a case of isolated recurrent intraventricular haemorrhages caused by AVM detected by diagnostic intracranial angiography with no abnormality demonstrated on angiography four years earlier.

CT-Cisternography in Post-Surgical CSF Rhinorrhea

Cerebrospinal fluid (CSF) rhinorrhea is a dangerous problem. CSF rhinorrhea implies an abnormal communication between the subarachnoid space and the nasal cavity, with subsequent leakage of CSF through the anterior nasal apertures. requiring surgical repair. Imaging techniques have evolved from conventional cranial radiography to polytomography, thin-section computed tomography (CT) and intrathecal water-soluble iodinated contrast agent-enhanced CT cisternography. We present two cases of post-surgical CSF rhinorrhea in which the best diagnostic findings were obtained by CT cisternography.

Acute Encephalitis of Unknown Etiology: Early Diagnosis and Follow-up of Disease Evolution. MRI

Two women with viral encephalitis of unknown etiology were studied with serial MR studies at 1.5 Tesla using: Spin-Echo (SE) T1-weighted (T1w) sequences before and after i.v. administration of paramagnetic contrast agent, with/without magnetization transfer (MT), Fast SE and Fluid-attenuated Inversion Recovery (FLAIR) T2-weighted sequences, Echo-Planar Single-Shot sequences for the assessment of water diffusivity (Diffusion Weighted, DW, and Apparent Diffusion Coefficient maps, ADC). The DW and T1w sequences with MT after contrast were most useful to detect the initial pathologic alterations, thereby reinforcing the clinical diagnostic hypothesis and prompting appropriate drug treatment, even if the laboratory data were not conclusive for viral etiology. In a later phase, both cases showed MR evidence of lacunar foci in the grey matter, and cortical laminar necrosis, probably indicating a concomitant hypoxic/ischemic mechanism.

Traumatic carotid cavernous fistula: failure of endovascular treatment with two stent-grafts

SUMMARY

We describe an unconventional endovascular approach in a young patient with large highflow traumatic carotid cavernous fistula that could not be treated by detachable balloon procedure. Two coronary stent-grafts were used to close the large tear of internal carotid artery. After the failure of stenting procedure, the fistula was successfully treated by trapping with two detachable balloons.

Plasma atrial natriuretic factor levels in the inferior petrosal sinus blood of patients with Cushing's disease before and after corticotropin-releasing hormone administration

Atrial natriuretic factor (ANF) was suggested to be involved as neurohormone in the modulation of hypothalamus-pituitary-adrenal axis in humans. However, this role is still controversial and widely discussed. In order to evaluate whether ANF is secreted in the hypothalamus-pituitary system in humans, plasma ANF concentrations were assayed in samples collected in the inferior petrosal sinus (IPS) blood of patients subjected to IPS sampling for diagnostic purposes or neurosurgical indications. In this retrospective study were included 22 patients: 10 with Cushing's disease (CD) and 12 patients with GH or PRL-secreting pituitary adenoma, used as control group. In the patients with CD, plasma ANF concentration was also assayed after CRH test (hCRH 100 micrograms as i.v. bolus with blood samples after 5, 10 and 15 min). Both in patients with CD and in patients with GH- or PRL-secreting pituitary adenoma, no significant difference was found in plasma ANF levels between IPS ipsilateral (13.0 +/- 1.5 and 12.2 +/- 1.2 pmol/l) or controlateral (13.0 +/- 1.6 and 12.2 +/- 1.4 pmol/l) to the adenoma and peripheral blood (14.2 +/- 2.0 and 13.7 +/- 1.5 pmol/l, respectively). Similarly, no difference was found between the IPS ipsilateral and controlateral to the adenoma in both groups of patients. In patients with CD, CRH administration induced a significant increase of ACTH levels (periphery: 34.9 +/- 6.2 vs 11.5 +/- 2.3 pmol/l, p < 0.05) but it did not induce any significant change of plasma ANF levels (14.0 +/- 2.0 vs 13.4 +/- 1.4 pmol/l in the ipsilateral IPS and 13.4 +/- 1.6 vs 13.4 +/- 1.5 pmol/l in the ipsilateral IPS and 13.4 +/- 1.6 vs 13.4 +/- 1.5 pmol/l in the contralateral IPS). In conclusion, the lack of ANF concentration gradient between IPS and peripheral blood, the lack of any difference in ANF concentrations between patients with CD and acromegalics or hyperprolactinemics and the absence of ANF response to CRH administration do not support the hypothesis of a role for ANF as neurohormone involved in the hypothalamus-pituitary control and particularly in the hypothalamus-pituitary-adrenal axis modulation in humans.

[Warthin's tumor. Description of 2 cases]

Warthin's tumor is a debated pathological condition. There are many controversies concerning this disease such as its origin (hereditary or acquired), its nature (whether neoplastic or no), its topographical relation with the salivary glands, its relationship with possible concomitant pathologies (dysmetabolic, infective, neoplastic, etc.), the problems of diagnosis and of differential diagnosis with all possible causes of cervical swelling, and also the problems of surgical treatment in relation to the possible involvement of the salivary glands. In this paper two clinical cases are described. The first one is characterized by a latero-cervical bilateral Warthin's tumor, apparently independent of the salivary glands, associated with rhinopharyngeal lymphatic hyperplasia and nodular colloid goiter. The second case is characterized by a latero-cervical uni-lateral Warthin's tumor, linked by a slender layer with the ipsilateral parotid gland, associated with breast cancer. Starting point from the discussion of these two cases, the Authors make remarks in order to answer some of the aforementioned questions.

Impaired luteinizing hormone responsiveness to gonadotropin-releasing hormone in the inferior petrosal sinuses of hyperprolactinemic patients

The aim of this study was to evaluate serum baseline and gonadotropin-releasing hormone (GnRH)-stimulated follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations in the inferior petrosal sinuses and in peripheral blood in nine normoprolactinemic and eight hyperprolactinemic patients who were being subjected to perihypophyseal phlebography for diagnostic purposes or neurosurgical indications. Serum FSH and LH concentrations were significantly higher in both inferior petrosal sinuses than in peripheral blood (p < 0.001 and p < 0.05, respectively) in normoprolactinemic but not in hyperprolactinemic patients. Additionally, in normoprolactinemic patients, the LH response to intravenous bolus GnRH in the inferior petrosal sinuses (evaluated as peak/basal) was significantly greater than in hyperprolactinemic patients (p < 0.01). No difference was found as far as FSH response to GnRH was concerned. In conclusion, these findings suggest that the hypogonadism of hyperprolactinemic patients may depend on the impaired release of LH at the pituitary level.

Corticotropin-releasing hormone test: improvement of the diagnostic accuracy of simultaneous and bilateral inferior petrosal sinus sampling in patients with Cushing syndrome

Twenty-six consecutive patients with ACTH-dependent Cushing syndrome were subjected to simultaneous, bilateral inferior petrosal sinus sampling for ACTH assay before and after ACTH-releasing hormone (CRH) stimulation. The baseline ACTH inferior petrosal sinus/periphery (IPS/P) ratio was > or = 2 in 12 of 26 patients (46%), whereas the CRH-stimulated IPS/P ratio was > or = 3 in 19 of 26 patients (73%). A pituitary adenoma, ACTH-secreting at immunostaining, was surgically proved in all of the 19 patients who had an ACTH IPS/P ratio > or = 2 basally or > or = 3 after the CRH test but also in three other patients who did not have such ratios. The value of the basal IPS/P ratio and the complete lack of ACTH increase after CRH led to the diagnosis of an ectopic ACTH syndrome in four patients: a bronchial carcinoid was found in three patients, and the site of the tumor was still unknown in the other. In conclusion, the CRH test improved the diagnostic accuracy of inferior petrosal sinus sampling from 61.5% (12 pituitary, 4 ectopic) to 92.0% (19 pituitary, 4 ectopic). Thus it should be performed during the diagnostic process.

Alpha-melanocyte-stimulating hormone is present in the inferior petrosal sinuses in patients with Cushing's disease

Plasma ACTH, beta-endorphin and alpha-melanocyte-stimulating hormone levels were evaluated in the inferior petrosal sinuses and in the periphery of 22 patients affected by Cushing's disease, 11 patients with other pituitary diseases subjected to simultaneous and bilateral inferior petrosal sinus sampling and in the peripheral blood of 15 normal subjects. In patients with Cushing's disease ACTH, beta-endorphin and alpha-melanocyte-stimulating hormone levels in the inferior petrosal sinus ipsilateral to the adenoma were significantly higher than in the periphery and in the contralateral inferior petrosal sinus (p < 0.01, p < 0.01 and p < 0.05, respectively). In patients with other pituitary diseases only ACTH and beta-endorphin, but not alpha-melanocyte-stimulating hormone levels in both inferior petrosal sinuses were significantly higher than in the periphery (p < 0.01). Furthermore, no difference was found in the peripheral blood among patients with Cushing's disease, patients with other pituitary diseases and normal subjects for ACTH and beta-endorphin level. By contrast, in patients with Cushing's disease peripheral alpha-melanocyte-stimulating hormone levels were significantly higher than in patients with other pituitary diseases and in normal subjects (p < 0.05). In conclusion, the results of the present study suggest that only in patients with Cushing's disease, but not in patients with other pituitary diseases, alpha-melanocyte-stimulating hormone is released by adenomatous pituitary corticotrophs together with ACTH and beta-endorphin.

Simultaneous and bilateral inferior petrosal sinus sampling for the diagnosis of Cushing's syndrome: comparison of multihormonal assay, baseline multiple sampling and ACTH-releasing hormone test

In 29 consecutive patients with adrenocorticotropin (ACTH)-dependent Cushing's syndrome, we compared the usefulness of multiple baseline ACTH evaluations (10/29), multiple hormone evaluation (29/29) and ACTH-releasing hormone (CRH) stimulation (21/29) during simultaneous and bilateral inferior petrosal sinus sampling. The basal inferior petrosal sinus/periphery ratio for ACTH concentrations was greater than 2 in 18 of the 29 patients and CRH challenge caused the appearance of an inferior petrosal sinus/periphery ratio greater than 3 in 6 other patients. The presence of an ACTH-secreting adenoma was surgically proven in all the 24 patients who had an ACTH inferior petrosal sinus/periphery ratio greater than 2 basally or greater than 3 after the CRH test but also in 1 patient who had an inferior petrosal sinus/periphery ratio lower than 2 basally or 3 after the CRH test. In 4 patients, both the very high peripheral ACTH levels, the inferior petrosal sinus/periphery ratio and the complete lack of ACTH increase after CRH indicated the presence of an ectopic ACTH syndrome: a bronchial carcinoid was found in 2 patients, whereas the site of the tumor is still unknown in the remaining 2. An ACTH intersinus gradient greater than 1.4 was found in 23 patients. Among these 23 patients, the side of the adenoma was correctly predicted in 19 patients and wrongly in 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenocorticotropic hormone and beta-endorphin concentrations in the inferior petrosal sinuses in Cushing's disease and other pituitary diseases

Aim of the present study was the evaluation of ACTH and beta-endorphin-like-immunoreactivity (beta-ELI) in the inferior petrosal sinuses (IPS's) and in the peripheral blood of patients with Cushing's disease (Group 1), with GH- or PRL-secreting adenomas or nontumoral hyperprolactinemia (Group 2). These patients had undergone selective and bilateral simultaneous IPS sampling for diagnostic purposes or for neurosurgical indications. In the patients of Group 1, ACTH and beta-ELI levels were higher in the IPS ipsilateral than in the contralateral to the adenoma and in the periphery (p < 0.001). In the patients of Group 2 ACTH and beta-ELI levels were higher in the IPS's than in the peripheral blood (p < 0.001) and, in the 9 patients with GH- or PRL-secreting adenomas, they were higher in the IPS ipsilateral than in the contralateral to the adenoma and in the periphery (p < 0.05). A significant correlation exists between ACTH and beta-ELI in the periphery (p < 0.01; r = 0.72), in the IPS ipsilateral (p < 0.05; r = 0.54) and contralateral (p < 0.01; r = 0.66) to the adenoma in Group 1, but not in Group 2. In conclusion, higher beta-ELI levels were detected in the IPS's than in the peripheral blood not only in patients with Cushing's disease but also in those with other pituitary diseases not involving ACTH secretion. The absence of correlation between ACTH and beta-ELI in patients not bearing Cushing's disease suggests that in these conditions corticotrophs release ACTH and beta-endorphin in an independent manner.

Hormonal gradients between inferior petrosal sinuses in various pituitary diseases

The aim of this retrospective study was to evaluate the existence of a multihormonal gradient between the inferior petrosal sinuses in various pituitary diseases: Cushing's disease (8 cases), acromegaly (4 cases), prolactinomas (7 cases), GH, PRL-secreting adenoma (1 case), functionless adenoma (2 cases), empty sella (3 cases) and in non-tumoral hyperprolactinemia (5 cases). A significant intersinus gradient (more than 1.4:1) was recorded for GH, ACTH and PRL in 16 patients (80%), but in only 9 patients (45%) out of the 20 with hormone-secreting tumors for TSH, FSH and LH. Moreover, of the 10 patients in the remaining groups, only in two cases was a significant intersinus gradient present: one for GH and one for LH. In conclusion, the finding of a multihormonal release in the inferior petrosal sinus ipsilateral to the adenoma is reported, for the first time, in patients with GH- and PRL-secreting adenomas. The possible explanation for such a finding may be either an increased blood flow in this site of sampling or a pituitary multihormone release through a paracrine mechanism primed by the tumoral hypersecreted hormone. In addition, the pulsatile secretory pattern and the short half-life of polypeptide hormones may contribute to better demonstrate this phenomenon in respect to glycoprotein hormones.

Comparison of anterior pituitary hormone levels in the inferior petrosal sinuses and peripheral blood in various pituitary disorders during perihypophysial phlebography

The present study aimed at evaluating the anterior pituitary hormone levels in the inferior petrosal sinuses and in the peripheral blood of 55 patients affected by various pituitary disorders and undergoing perihypophysial phlebography on neurosurgical indication or for diagnostic purposes. The results indicated that in 6 patients with Cushing's disease and in 4 with hyperprolactinemia the secreting adenoma could be localized by inferior petrosal sinus sampling. Furthermore, the concentrations of all the pituitary hormones were found to be higher in the right and/or in the left inferior petrosal sinus than in peripheral blood, showing a clear gradient between central and peripheral samples. Moreover, the evaluation of hormone central/peripheral concentration ratios revealed noteworthy differences, namely, that central/peripheral concentration ratios of GH, ACTH, and PRL were significantly higher than those of TSH, FSH, and LH (p less than 0.01). On the contrary, no significant differences were found when the concentration ratios of GH, ACTH and PRL or TSH, FSH and LH were compared among themselves. This finding may be attributed to at least two factors: the increased pulsatility and the relatively short biological halftime of polypeptic hormones (GH, ACTH, and PRL) compared with glycoprotein hormones (TSH, FSH, and LH).

Intracerebral haemorrhage: criteria for prognosis on the grounds of clinical and CT data

The Authors report analyses on 83 cases of brain haemorrhage which were conducted over a period of 6 years. On the basis of previous studies made by the same authors, a selection was made from patients whose survival index rating did not exceed 8.1. These patients were treated only with medical and reviving therapies. In this work we attempt to formulate some considerations regarding the prognosis of brain haemorrhage on the basis of clinical and tomodensitometric data.

[MR vs CT: which is the diagnostic advantage in neuroradiology]

The comparative adequacy was studied of the two main neuroradiological imaging methods, MR imaging and CT, through the analysis of 1500 MR examinations with a preliminary CT study. The comparison was made by giving a score to the diagnostic contribution of MR imaging, especially as far as changes in the therapeutical approach were concerned. The results varied according to the various pathologies, to the different anatomical regions explored, and to the site of the masses. The overall score was higher in the spine and the spinal cord than in brain pathology. In brain neoplastic pathology, eg, the diagnostic capabilities of CT and MR imaging were similar in most cases, especially in supratentorial locations, while MR imaging was clearly superior in the spinal cord district. In infratentorial location, the better anatomical details make MR imaging the method of choice. In conclusion, CT confirms its accuracy in the detection of brain pathology, while MR imaging proves more sensitive in white matter diseases, and in particular locations, e.g. the posterior fossa. In the spine and spinal cord districts, the very high average score mainly confirms MR capability to demonstrate spinal canal normal and pathological content. Moreover, the important role of MR imaging is stressed in pediatric pathology, together with CT primary role in emergency cases.

Postoperative lumbar arachnoidal diverticula

Five patients with arachnoidal diverticula after lumbar operations are reported. Myelography was performed in all cases, spinal computed tomography scanning in three; three patients underwent surgical treatment with good clinical results. Arachnoidal diverticula are a rare complication of operations on the lumbar spine. Spinal computed tomography scanning is very useful, especially in the investigation of large diverticula and in the radiologic visualization of the arachnoidal stalk. Surgical treatment, which is required in symptomatic cases, results in remission of pain and prevents neurological complications.

[The spinal vacuum phenomenon. Radiographic and tomodensitometry aspects]

The spinal vacuum phenomenon is readily recognized by computed tomography: there fore its observation has become frequent enough. The side of the gaseous collection (intervertebral disk, vertebral body, apophyseal joint) depends on the disease inducing the phenomenon. Radiological and CT aspects of this findings are discussed. The usefulness of vacuum phenomenon in the diagnosis of several pathological conditions is examined.

[Radiological investigation of prolactin-producing pituitary microadenomas (author's transl)]

The CT scans and thin section sellar tomograms of 12 patients with amenorrhea, galactorrhea and hyperprolactinemia syndrome were analyzed. Three patients showed a remodeled sella on plain X-ray of the skull and a protrusion of the suprasellar cistern below the diaphragmatic line on pneumoencephalography (empty sella). CT scan confirmed the low absorption values within the sella and showed an intrasellar area of increased density after contrast infusion. In 9 patients, thin section tomograms showed an abnormal sellar configuration. 5 of these patients had an eccentric, high density area adjacent to the sellar floor on postcontrast CT scans. The remaining 4 patients did not show postcontrast enhancement.

[Myelography with B 15000, a new nonionic water-soluble contrast medium. Technical aspects and preliminary clinical experiences (author's transl)]

This is a report of myelography findings obtained in 50 patients with B 15000 (Iopamidol), a new non ionic water-soluble contrast medium. The procedure was easily carried out with a tilting table wired to a TV image amplifier. The dose of contrast medium injected intrathecally was 10 divided by 15 cm3 of a preconstituted solution containing iodine 200 or 300 mg/cm3. There were no accidents or major complications. The myelograms obtained with the test material afforded accurate diagnosis of intramedullary and extramedullary lesions, and signally of intervertebral disk protrusion and hernia.