IL-6 Quotient (The Ratio of Cerebrospinal Fluid IL-6 to Serum IL-6) as a Biomarker of an Unruptured Intracranial Aneurysm

Background

Studies conducted so far have focused mainly on the assessment of IL-6 levels in patients with ruptured brain aneurysms. Carrying out detailed studies in patients with un-ruptured brain aneurysms (UIA) would be extremely important, as it would answer the question of whether IL-6 plays also a role in primary aneurysm formation and growth.

Methods

IL-6, S100, NSE, and albumin concentrations in 67 UIA patients and 17 individuals without vascular lesions in the brain were tested using in vitro diagnostic immunoassays according to the manufacturers' instructions. IL-6 Quotient was calculated by dividing cerebrospinal fluid (CSF) IL-6 by serum IL-6.

Results

We showed that IL-6 Quotient was significantly higher in UIA patients (1.78) compared to the control group (0.87; p<0.001). Multivariate logistic regression analysis demonstrated that a growth in IL-6 Quotient increases the probability of UIA diagnosis. In UIA patients CSF IL-6 concentration was significantly higher (4.55 pg/ml) compared to the serum concentration (2.39 pg/ml; p<0.001). In both the study and control group, the blood-brain barrier was intact, thus the CSF-blood gradient of the IL-6 concentration in UIA patients was likely to be the expression of local synthesis of the cytokine within the central nervous system. Patients with multiple brain aneurysms had significantly higher CSF IL-6 levels (5.08 pg/ml) compared to individuals with a single aneurysm (4.14 pg/ml; p=0.0227).

Conclusion

This totality of the may suggest IL-6 as a biomarker for UIA formation; however, further studies are needed to unequivocally confirm clinical application of IL-6 concentration evaluation.

Myelin-associated proteins are potential diagnostic markers in patients with primary brain tumour

INTRODUCTION

Taking into account the possibility of myelin-associated proteins having a role in brain tumour development, the study aimed to evaluate the diagnostic usefulness of myelin-associated proteins (Nogo-A, MAG, OMgp) released into extracellular space in patients with brain tumours.

PATIENTS AND METHODS

Protein concentration in primary brain tumour (n = 49) and non-tumoural subjects (n = 24) was measured in cerebrospinal fluid (CSF) and serum by means of ELISA. Immunohistochemistry for IDH1-R132H was done on 5-μm thick formalin-fixed, paraffin-embedded tumour sections with the use of an antibody specific for the mutant IDH1-R132H protein.

RESULTS

The receiver operator characteristic curve analysis showed that CSF Nogo-A and serum MAG were useful in differentiating patients with primary brain tumour from non-tumoural individuals. This was also true in the case of the separate analysis of the astrocytic tumour versus non-tumoural groups and the meningeal tumour versus non-tumoural groups. Neither Nogo-A nor MAG or OMgp concentrations were significantly different, in serum or CSF, between IDH1 wild-type astrocytic brain tumour patients compared to IDH1 mutant patients.

CONCLUSIONS

Our results indicated the potential usefulness of CSF Nogo-A and serum MAG evaluation as circulating biomarkers of primary brain tumours. Because blood is relatively easy to obtain, future research should be conducted to explicitly indicate the value of serum MAG concentration evaluation as a brain tumour biomarker.Key messagesMyelin-associated proteins may be circulating brain tumour biomarkers.Nogo-A and MAG proteins seem to be the most useful in brain tumour diagnosis.Decreased CSF Nogo-A concentration is an adverse prognostic factor for patients' survival.

Endoscopic transconjunctival optic nerve sheath fenestration for progressive idiopathic visual field deficit: a case report

Intra-orbital optic nerve sheath fenestration (ONSF) is an effective option in patients with progressive vision loss due to idiopathic intracranial hypertension. Most proposed techniques involve surgical trauma and require disinsertion of the medial rectus muscle; thus, less invasive surgical procedures are needed. Here, a feasible and effective technique of endoscopic intra-orbital ONSF through a conjunctival incision is presented, in a patient with a progressively compromised visual field, papilloedema, and distended subarachnoid space around the optic nerves. The retrobulbar segment of the optic nerve was exposed for incision, avoiding manipulation of the lateral orbital rim bones and irritation of the ciliary microvessels and nerves. The patient regained the entire visual field. ONSF was safely and effectively performed endoscopically through a narrow corridor gained by brushing away the orbital fat with minimal traction on the medial rectus muscle. The small postoperative wound was associated with faster and easier convalescence, and less tissue trauma versus conventional open approaches.

Large prospective validation and cultural adaptation of the Polish version of the Swiss Spinal Stenosis Questionnaire for patients with lumbar spinal stenosis

OBJECTIVE

The aim of this prospective cohort study was to translate, validate and perform a cultural adaptation of the Polish version of the Swiss Spinal Stenosis Questionnaire (P-SSSQ), a disease-specific questionnaire for assessing symptom severity, physical function and satisfaction with treatment in patients with lumbar spinal stenosis (LSS).

MATERIAL AND METHODS

Patients were prospectively recruited at two orthopedic centres in Krakow, Poland, between January 2011 - October 2016. During the interview, each patient completed the P-SSSQ, SF-36 Health Survey, and a demographic data questionnaire. After translation, cross-cultural adaptation, and pilot testing, assessment was made of the internal consistency, test-retest reliability, construct validity, and responsiveness of the P-SSSQ subscales.

RESULTS

Finally, 171 consecutive patients were included in the study. Cronbach's alpha and ICC values were above 0.8 for all three subscales of the P-SSSQ. The symptom severity domain was highly negatively correlated with physical functioning and bodily pain of SF-36, with Pearson correlation coefficients of -0.68 and -0.63, respectively. The physical function domain was highly negatively correlated with physical functioning (r = -0.62). The satisfaction subscale was also highly negatively correlated with the change in the symptom severity (r = -0.61) and physical function scale (r = -0.65).

CONCLUSIONS

The proposed version of the P-SSSQ showed excellent measurement properties and can be considered validated for use in Polish. It is easy to understand, quick to complete, and the psychometric properties of the original version are maintained.

IMPACT OF MINIMALLY INVASIVE DECOMPRESSION SURGERY ON THE QUALITY OF LIFE OF PATIENTS WITH LUMBAR SPINAL STENOSIS – A 2 YEAR FOLLOW-UP STUDY

Background: Lumbar spinal stenosis (LSS) may result in a progressive narrowing of the spinal canal leading to compression of the nerve roots. The advantages of minimally invasive surgical approaches to the lumbar spine have been rigorously evaluated, however, the long-term impact on the health-related quality-of-life (HRQoL) of patients with LSS that have undergone minimally invasive decompression surgery is uncertain. To this end, the aim of our study was to evaluate the impact of this procedure on the HRQoL of patients with LSS. Methods: Enrolled patients were recruited to this prospective study at two orthopedic centers in Krakow, Poland. Patients eligible for inclusion were above 18 years of age, had been qualified for spine surgery of the lumbar region due to either discopathy or non-traumatic spinal stenosis, had uni- or bilateral neurogenic claudication, and verified spinal stenosis. During the interview, each patient completed the Polish version of the SSSQ (P-SSSQ), SF-36, and a demographic data questionnaire. Apart from the preoperative assessment the patients were again approached to fill in the questionnaires 6, 12, 18, and 24 months postoperatively. Results: One hundred and seventy-one consecutive patients with a mean age of 59 years were included in the study. This study found that LSS decompression statistically significantly increases HRQoL in a 2-year observation. There was a significant difference between the preoperative and postoperative SF-36 and P-SSSQ scores. The largest increase in HRQoL is between the preoperative period and 6 months post-op (p&lt;0.0001). Starting from around 18 months post-op, further changes in HRQoL are minimal. Late complications (persistent pain, the need for revision surgery) may decrease HRQoL at around 24 months post-op. Conclusions: Minimally invasive decompression surgery for elderly patients with LSS significantly improves their HRQoL

Correlation of leptin receptor expression with BMI in differential grades of human meningiomas

Meningioma is one of the most common primary brain tumor, especially in postmenopausal women. The most important risk factors include radiation, primary head injury or genetic alterations, however it is currently unclear why postmenopausal women are predominantly affected. The aim of the present study was to evaluate leptin receptor (LEPR) expression and body mass index (BMI) in patients with meningiomas of differential grades. Specimens of 158 meningiomas were classified as either G1 (low-grade meningiomas, n=114) or G2/G3 (high-grade meningiomas, n=44). Immunohistochemistry was performed to assess LEPR expression. The mean BMIs of the female and male patient groups were 28.43±5.29 and 23.93±4.66, respectively. Mean BMI was significantly higher in the female group, by ~4.50 kg/m2. Patient age significantly correlated with LEPR expression, with the highly positive (++) and positive (+) groups having mean ages of 62.3±12.07 and 52.3±13.04, respectively. A strong positive correlation (r=0.73) was observed between leptin receptor expression and BMI, with the LEPR (++) group having a mean BMI of 30.11±4.49, compared to 22.12±2.48 for the LEPR (+) group. Furthermore, in the low-grade meningioma group, mean BMI was higher in female patients than male patients (28.13±5.54 and 25.38±4.57, respectively; P=0.01). Additionally, there was strong positive correlation between BMI and leptin receptor expression in the low-grade meningioma group (r=0.69). For the high-grade meningioma group, mean BMI was 29.49±4.26 and 21.76±3.98 in female and male patients, respectively, and LEPR expression strongly correlated with BMI in this group (r=0.80). The present study demonstrates a correlation between patient BMI, age, and LEPR expression status in low- and high-grade meningiomas. Our results indicate that in addition to endogenous hormones, such as estrogen or progesterone, or fatty tissue-associated proinflammatory cytokines, LEPR expression status may be a risk factor for meningioma growth and progression.

The role of polymorphisms of genes encoding collagen IX and XI in lumbar disc disease

The intervertebral disc disease (IDD) is one of the most common musculoskeletal disorders. A number of environment and anthropometric risk factors may contribute to it. The recent reports have suggested the importance of genetic factors, especially these which encode collagen types IX and XI. The allelic variants in the collagen IX genes - COL9A2 (Trp2) and COL9A3 (Trp3) have been identified as genetic risk factors for IDD, because they interfere the cross-linking between collagen types II, IX and XI and result in decreased stability of intervertebral discs. Type XI collagen is a minor component of cartilage collagen fibrils, but it is present in the annulus fibrosus and nucleus pulposus of intervertebral discs. Some studies have shown the association between gene COL11A1 polymorphism c.4603C>T and IDD. The frequency of 4603T allele was significantly higher in the patients with IDD than in the healthy controls.

[Intraneural ganglion of the peroneal nerve--two case reports]

This paper describes two cases of gelatinous cyst of rare location within the peroneal nerve. Clinical picture was different in described patients. The gelatinous cyst was completely resected in both cases. The final diagnosis was established based on the histo-patological examination.

360 degree decompresion and stabilisation of the C6-C7 cervical spine luxation - case study

We present the operative technique employed in a young man with cervical spine luxation at the level of C6-C7 with clinical signs of damage to the spinal cord at the level of C5. In order to achieve an optimal therapeutic effect (decompression of neural structures and spinal stabilisation) during one surgical procedure, the positioning of the patient was changed twice during the procedure. Considering the positioning of the patient at the beginning of the procedure, the body position was changed by 360 degrees. The first part of the procedure was performed from an anterior approach with the patient in the supine position. It involved a C6-C7 discectomy and removal of the upper surface of the body of C7, which was protruding into the vertebral canal and compressing the spinal cord. Intraoperative inspection showed that a posterior approach was necessary to reduce the luxation. Therefore, for the second part of the operation, the patient was turned by 180 degrees and placed in the prone position. For the last (third) part of the surgical procedure, the patient was again turned by 180 degrees and placed in the supine position in order to insert an anterior spine fixator. We believe that a procedure utilising different surgical approaches and different positioning of the patient in order to achieve optimal therapeutic effect may be used in selected cases in everyday clinical practice.

[C1-C2 transarticular screw fixation of atlanto-axial instability with tetraparesis in rheumatoid patient--case report]

A case of a 50-year-old patient with C1-C2 subluxation and concomitant neurological deficits in the course of rheumatoid arthritis has been described. In the article the diagnostic and therapeutic procedures, consisting mainly of surgical treatment, have been presented. Indications for the surgery were: a rapid disease progression observed during the last six months, and tetraparesis. The authors propose the choice of applied surgical technique by taking into account difficulties consequential to the anatomy of this region, as well as additional complications regarding the chronic inflammation process. The use of transarticular screw fixation method, together with concurrent spinal cord decompression allowed the stabilization of C1-C2 subluxation and improvement of the neurological state of the patient.

[The clinical value of transpedicular thoraco-lumbar spine stabilisation]

The authors present the results of treatment of spine neoplastic disease using transpedicular stabilisation. The clinical material of 2004 year are 20 cases, 15 males (75%) and 5 female (25%), 19 of them were qualified to the surgical treatment (95%). Obtained outcomes permit authors to make confirmation that the transpedicular stabilisation of thoraco-lumbar spine as a surgical treatment of it's neoplastic disease decrease pain, improve neurological condition if spinal cord damage are not durable, makes easer the rehabilitation process and nursing care.

[Syringomyelia--is it only a problem in neurosurgery?]

Three cases of arthroplasty in the course of syringomyelia are presented. These patients have been diagnosed in orthopedic-traumatologic department due to their bony/articular symptoms. After having established the diagnosis the patients were referred to Neurosurgery. Final diagnosis of syringomyelia requires computerized tomography and magnetic resonance imaging. Syringomyelia necessitates an early surgical treatment.

[Impact of hormonal prevention on fractures of the proximal femur in postmenopausal women: a simulation study]

A simulation model of the effects of hormone replacement therapy (HRT) on hip fractures and their consequences is based on a population of 100,000 post-menopausal women. This cohort is confronted with literature derived probabilities of cancers (endometrium or breast, which are contra-indications to HRT), hip fracture, disability requiring nursing home or home care, and death. Administration of HRT for life prevents 55.5% of hip fractures, 22.6% of years with home care and 4.4% of years in nursing homes. If HRT is administered for 15 years, these results are 15.5%, 10% and 2.2%, respectively. A slight gain in life expectancy is observed for both durations of HRT. The net financial loss in the simulated population is 222 million Swiss Francs (cost/benefit ratio 1.25) for lifelong administration of HRT, and 153 million Swiss Francs (cost/benefit ratio 1.42) if HRT is administered during 15 years.

Data bases for the assessment of medical technologies. Examples from Europe

The assessment of medical technologies has to answer several questions ranging from safety and effectiveness to complex economical, social, and health policy issues. The type of data needed to carry out such evaluation depends on the specific questions to be answered, as well as on the stage of development of a technology. Basically two types of data may be distinguished: (a) general demographic, administrative, or financial data which has been collected not specifically for technology assessment; (b) the data collected with respect either to a specific technology or to a disease or medical problem. On the basis of a pilot inquiry in Europe and bibliographic research, the following categories of type (b) data bases have been identified: registries, clinical data bases, banks of factual and bibliographic knowledge, and expert systems. Examples of each category are discussed briefly. The following aims for further research and practical goals are proposed: criteria for the minimal data set required, improvement to the registries and clinical data banks, and development of an international clearinghouse to enhance information diffusion on both existing data bases and available reports on medical technology assessments.

Early pulmonary endothelial enzyme dysfunction after phorbol ester in conscious rabbits

We investigated changes in angiotensin converting-enzyme (ACE) activity before and at 5, 15, 60, and 240 min after 20 micrograms phorbol myristate acetate/kg body wt iv in conscious rabbits. ACE activity was estimated in vivo from the single-pass transpulmonary metabolism of the synthetic substrate [3H]benzoyl-Phe-Ala-Pro [( 3H]BPAP) under first-order reaction conditions. Within 5 min after PMA administration, all animals developed profound granulocytopenia (15% of control) and moderate thrombocytopenia (57% of control), both lasting for the duration of the experiment. Concomitantly, there was a significant decrease in the transpulmonary metabolism of [3H]BPAP and the calculated apparent first-order reaction constant Amax/Km of ACE for [3H]BPAP. No histological evidence of lung injury was observed at these times. Since a concomitant fall in the permeability surface area product for urea was also observed, we considered that the apparent decline in ACE activity might have resulted from a reduction in perfused endothelial surface area. To resolve this, we studied the effect of PMA on the Km (a measure of enzyme affinity for its substrate) and Amax (a derivative of Vmax that is dependent upon total enzyme present and thus capillary surface area) of ACE and 5'-nucleotidase for [3H]BPAP and [14C]AMP, respectively. A significant increase in Km for both enzymes was observed at 1 h after PMA, whereas Amax was unaffected, suggesting that low-dose PMA may indeed produce endothelial cell enzyme dysfunction independent of its effect on capillary surface area. These results provide evidence of pulmonary capillary functional injury before or in the absence of structural endothelial damage.

Swiss Hospital Institute's approach to the problems of magnetic resonance imaging

The Swiss Hospital Institute, a nonprofit institution that provides guidance on hospital planning and operation to Switzerland's health care community, conducted in 1984 a comprehensive study of magnetic resonance imaging (MRI) and magnetic resonance spectroscopy via a 17-member commission that examined all aspects of these emerging technologies. Future MRI utilization was estimated by developing five clinical categories of possible MRI use, based on ICD codes, and a probability of MRI utilization was developed for each category. By applying these probabilities to the number of inpatient admissions in each category, an annual nationwide volume of 20,000 scans was estimated. Ten MRI systems were considered adequate for a period of up to five years after the report's promulgation, based on a per-system annual throughput of 1,900-2,000 patients. A superconducting-magnet system with an 0.5-T field strength was deemed the most suitable, with units to be located in university hospitals. [Spectroscopy was considered best left to separate research installations.] The cost of equipment and construction for the 0.5-T superconducting magnet system were calculated as high as 3.6 million Swiss francs (Sfr) (approximately $1.65 million at fall 1985 exchange rates). the annual operating cost was estimated as Sfr 1.3 million ($600,000). On this basis a per-study fee of Sfr 690 ($315) was projected. The study recommended health insurance coverage of MRi use, only in patients with well-proven clinical indications for an MRI scan. The report is expected to aid in the orderly introduction of MRI into Switzerland's health care system.

The effect of alphanapthylthiourea (ANTU)-induced acute injury on lung binding of antibody to angiotensin converting enzyme (ACE)

The effects of ANTU-induced acute pulmonary capillary injury on lung and serum ACE functional activity and the specific accumulation of radio-labelled anti-ACE in lung were explored. Rats were injected either with ANTU or the solvent and sacrificed at various intervals up to one week after injection. All ANTU-injected animals developed pulmonary edema and bilateral pleural effusions which resolved by the one week time point. At no time was there any significant change in serum ACE levels. The specific activity of total lung ACE however rose from 11.0 +/- .95 (mean +/- SEM) to 18.4 +/- 1.1 by two hours after ANTU; by 24 hours, however, solubilized lung ACE had fallen significantly to 6.9 +/- .79 (p less than .01). Total lung ACE had returned to control values by one week. In parallel groups of animals the accumulation of 125I-labelled anti-ACE (AA) or normal sheep immunoglobulin (NSG) was compared in control and ANTU-treated rats. The ratio of the radioactivity in the lungs of AA--injected animals to that in NSG--injected animals fell significantly after ANTU administration (5.0 +/- .88 to 1.2 +/- .28 at 2 hours) suggesting that immunoreactive ACE had fallen despite an increase in ACE functional activity. The decreased binding of AA at the early time points perhaps reflects internalization of endothelial cell ACE in response to injury and an inability of the antibody to interact with the enzyme. The reduction in binding at 24 hours (1.38 +/- .47) correlates with a reduction in total lung ACE. ANTI-ACE may be a useful reagent for quantitating endothelial cell damage following lung injury.

The assessment of medical technologist. Examples from Switzerland

The need for assessment of new medical technologies has recently become evident in many countries, especially for the people responsible for health care policy. There are multiple reasons for making evaluation: rising costs in health care, medical efficacy, safety, as well as social and political issues. Each stage of life of a diagnostic, therapeutic or preventive technology, from its emergence to obsolescence, can be assessed by an appropriate procedure. In Switzerland, a country with decentralized health care as well as political systems, the assessment is made by various institutions. Evaluative aspects are included in some National Research Foundation programs. Most work, however, is done by the division of medical techniques at the Swiss Hospital Institute. The panel of experts has recently prepared a report on magnetic resonance imaging (MRI). As a result of the initial evaluation, the need for this new technology in this country, and the number and sites of MRI systems for the next few years were established. The capital, running and unitary costs of this diagnostic procedure were estimated. The report will be of aid to the people planning investments and dealing with questions of reimbursement and other issues of health care policy. The methods of epidemiology, biostatistics, sociology and health economics used by the institutes of social and preventive medicine are very helpful in the procedures of technology assessment.

Prognostic value of neonatal CT scans in asphyxiated term babies: low density score compared with neonatal neurological signs

Twenty-five asphyxiated term babies were investigated in order to evaluate the prediction of their neurodevelopmental outcome by means of computerized tomography (CT) as compared to neurological symptoms during the neonatal period. Low density (LD) areas, thought to represent hypoxicischaemic lesions, were assessed quantitatively by means of a LD score based on the extent and degree of LD, the total score ranging from 0-36. Neonatal scans were defined according to the time span elapsed between asphyxia and CT as (1) early CT (day 1-7, n = 15), and (2) intermediate CT (day 9-23: n = 14; day 29: n = 1). The newborns were classified according to the neonatal neurological findings as having mild (n = 8, 32%), moderate (n = 9, 36%), and severe (n = 8, 32%) encephalopathy, following the definition of Sarnat and Sarnat (1976). Among the twenty-two survivors, the follow-up (mean age 19.2 +/- 6.0 mts) revealed fourteen (56%) with normal outcome, two (8%) with transient neurodevelopmental anomalies during the first year, and nine (36%) with permanent abnormalities such as cerebral palsy and/or retardation (mainly global) and/or epilepsy. Early CT scans had no predictive value. Intermediate CT, however, showed distinct variations of LD areas which resulted in an LD score well correlated with the later outcome. In particular, a LD score below 14 characterized every baby who developed normally; a prediction not possible in a reliable way be means of neonatal neurological signs. For all abnormal children, the score correlated with the severity of the later neurodevelopmental disorder, except for one with the latest intermediate CT (day 29).

Temporal evolution of hypoxic-ischaemic brain lesions in asphyxiated full-term newborns as assessed by computerized tomography

Hypoxic-ischaemic brain lesions may be detected as low density (LD) areas by means of computerized tomography (CT), but the clinical significance of such LD areas has been controversial. Since timing might be a critical factor, we studied the temporal evolution of LD areas in 9 asphyxiated term babies who had had two or more CT, and compared the changes to the neurodevelopmental outcome. Scans were classified according to the elapsed time after asphyxia as early (day 1-7, n = 6), intermediate (week 2-4, n = 7; week 4-7, n = 3) and late CT (3 months or more, n = 7). In early scans, no, or only ill defined, LD areas were seen in the periventricular region. In intermediate CT's, LD-zones were further diminished in those babies who later were normal. Sharply accentuated LD areas, however, appeared in those who later suffered from neurodevelopmental disorders. These LD areas, probably representing hypoxic-ischaemic lesions, were located periventricularly, extending into the subcortical white matter and the cortex, and usually involved both hemispheres symmetrically. They began to disappear at 4 to 7 weeks in some regions, possibly because of glial proliferation. LD persisting more than 4-7 weeks tended to transform into cyst-like lesions, or marked atrophy. We conclude (1) that hypoxic-ischaemic lesions appear as zones of low density on CT scans performed after the first week and (2) that the extent of such lesions can best be assessed between 9 to 23 days after asphyxia.

Congenital hemiparesis: the spectrum of lesions. A clinical and computerized tomographic study of 37 cases

Cerebral computerized tomography (CT) was obtained in 37 children with congenital hemiparesis to document the type of cerebral anomalies found in this group, correlate them with various features of the neurological handicap and clinical history and determine the prognostic and practical value of this examination in a newly diagnosed case. The CT-findings were: 1. normal CT: 4 children (11%); 2. unilateral ventricular enlargement: 9 children (24%); 3. others (cortical and subcortical lesions): 24 children (63%). In this latter group, special patterns were found: a) focal ischemic lesions: 7 cases; b) cystic porencephaly: 2 cases; c) ventricular deformities with hydrocephalus: 7 cases; d) varia: 8 cases. The children with normal CT or unilateral ventricular enlargement had mild or moderate hemiparesis without epilepsy or mental retardation. The third group comprised the more severe cases but the prognosis was very variable. The different types of CT-lesions, their possible origin and neuropathological correlates are described and compared with two previous studies. The variety of lesions found in this series and the relative prognostic value of the CT-Scan justify this examination in a newly diagnosed case.

Endotracheal administration of atropine sulfate

Atropine sulfate was successfully administered endotracheally to a 74-year-old patient suffering profound bradycardic cardiovascular collapse. Ninety seconds following endotracheal atropine administration, normal blood pressure and pulse were established. Therapeutic blood levels of atropine were documented following endotracheal administration. The endotracheal route for atropine administration appears to provide an effective alternative route of administration when intravenous access is difficult or impossible to establish rapidly.

The contrast media used for myelography

A review of the contrast media used for myelography and radiculography is presented. Water-soluble, nonionic medium like metrizamide enables the examination of the entire CSF space. The relation of the diagnostic benefit to complications when using this contrast medium is favorable. Attention must be paid in using the correct myelographic technique and in controlling the possible severe adverse reactions which appear in 1.5% of the cases during 24 h after the examination.

Transient ischemic attacks and external carotid artery. A retrospective study of 23 patients with an occlusion of the internal carotid artery

Twenty-three patients with occlusion of an internal carotid artery have been followed 5 to 50 months after angiography. None had a later permanent stroke. Eight had delayed TIAs in the occluded internal carotid area, never in another area. In these TIAs the role of the homolateral external carotid artery is emphasized, because in the 8 cases this artery was the main collateral to the occluded internal carotid, and angiography had shown atheromatous stenosis of homolateral external/common carotid arteries or an irregular stump at the site of the occlusion. Hemodynamic and embolic mechanisms are discussed, especially the latter, because of the absence of severe stenosis and evidence of emboligenic plaques.

Bone scan and angiography for orbitofrontal cholesterol granuloma

A case of a cholesterol-containing granuloma of the orbit studied by bone scanning and selective carotid angiography is presented. Bone scanning with 99mDisphosphonate disclosed a solitary focus of intense activity in the right orbitofrontal region. On the selective angiogram of the right external carotid artery a faint vascular blush was found in the orbital wall.