Elieser Avrahami

Early MR demonstration of spinal metastases in patients with normal radiographs and CT and radionuclide bone scans.

Forty patients with known primary tumor and progressive back pain, suspected of having spinal metastatic disease, underwent magnetic resonance (MR) examinations of the thoracic and lumbosacral spine. Conventional radiographs and CT scans of the spine were all normal. The radionuclide bone scans were equivocal. In 21 patients focal or diffuse vertebral MR abnormalities were detected. In nine patients the lesions were hypointense on T1 sequence, and the same lesions were demonstrated poorly or not at all on T2 and proton density sequences. In eight other patients the bone marrow metastases presented with strong signal intensity on T2 and were poorly or not at all demonstrated on T1 and proton density sequences. In three patients with multiple myeloma, the signal intensity pattern of the vertebrae was diffusely heterogeneous, with alternating small foci of strong and weak signals (a mosaic-like pattern). Following the MR studies, needle biopsy confirmed the malignancy in the 21 patients who had shown abnormalities. No correlation between the type of primary tumor and the signal intensity of the vertebral metastases was shown. Possibly the mosaic pattern shown in three of the multiple myeloma patients represents a special case.

MRI demonstration and CT correlation of the brain in patients with idiopathic intracerebral calcification.

Twenty-two patients aged 36–63 years were diagnosed as having Fahrs syndrome on the basis of the presence on CT of unexpected extensive calcification of the basal ganglia. Even when associated with calcification of other brain areas, the main diagnostic criterion remained basal ganglia calcification larger than 800 mm2. Normal values of parathormone, serum calcium and phosphorus excluded hypercalcaemia and hypoparathyroidism. Mitochondrial CNS disease was excluded clinically. MRI and repeated CT and neurological examination were performed in all of the patients. The patients were divided into two groups: neurologically asymptomatic (group 1) and neurologically symptomatic (group 2). T2-weighted sequences demonstrated hyperintense areas in all of the patients involving the white and the grey matter of the brain. In group 1 the hyperintense lesions were significantly smaller than in group 2. The neurological symptoms correlated better with the hyperintensities on T2-weighted MR images than with the calcification demonstrated on CT. Hyperintensities in T2-weighted MRI and the areas shown by CT to have calcification had different locations. In 15 patients with dementia, the white matter of the entire centrum semiovale was bilaterally hyperintense. In another 3 patients with hemiparesis, hyperintense areas in the internal capsule, contralateral to the side of hemiparesis, were demonstrated in the T2-weighted sequence. The hyperintense T2 signals may reflect a slowly progressive, metabolic or inflammatory process in the brain which subsequently calcifies and are probably responsible for the neurological deficit observed.

Spina Bifida Occulta of S1 Is Not an Innocent Finding

One thousand two hundred patients (600 women and 600 men) aged 18 to 72 years were referred for computed tomographic examination of the lumbosacral spine (L3-S1) after low-back pain or sciatica. Patients with spinal abnormalities other than spina bifida occulta (SBO)-S1 and findings other than posterior herniation of intervertebral disc were not included in this study. All of the patients underwent conventional radiographs of the lumbosacral spine. The incidence of SBO-S1 was higher in younger age groups and decreased with age. Patients with SBO-S1 showed a higher incidence of posterior disc herniation, which increased with age. This can be explained by instability of the base of the lumbar spine caused by SBO-S1, which produces a predisposition to posterior disc herniation. The results were statistically significant.

CT demonstration of intracranial bleeding in term newborns with mild clinical symptoms

This paper presents symptomatic term newborns with negative ultrasound examination which showed intracranial bleeding demonstrated by CT scan. Fifty-eight term newborns with Apgars of 9-10 were referred for repeat CT examination of the brain with symptoms, such as apnea, disturbances of swallowing or sucking, impaired muscular tonus, tremor and jerks. The ultrasound examination in all was normal. The first CT scan was performed 12-13 h after delivery. The second CT scan was performed at least two weeks later. Twenty-three of the patients underwent lumbar puncture. Physical examination was performed on each patient--at birth and one week later. The clinical symptoms were still present at the time of the second physical examination. Fourteen to seventeen months following the delivery, the psychomotor development was evaluated in 29 of the children using the Gesell test. In five children, the diagnosis of psychomotor retardation was established which correlated with the brain atrophy demonstrated on CT. Twenty-three newborns who underwent lumbar puncture showed evidence of bleeding into the subarachnoid space. The blood haemoglobin levels of all the cases was below 18 g/dl. The first CT examination demonstrated blood in the subarachnoid space. The second CT scan did not demonstrate any findings. Intracranial bleeding in newborns may be associated with normal delivery. The demonstration of high densities in the first CT scan, the normal second CT scan, the blood tinged or xantochromic CSF and the normal blood haemoglobin levels are indicative of intracranial bleeding.

CT of minor intubation trauma with clinical correlations

Even when performed by an experienced physician, endotracheal intubation is more traumatic than previously supposed. Following emergency intubation, patients have little probability of having a normal larynx. One-hundred patients underwent CT scan of the larynx 6 months or more following endotracheal intubation of short duration (up to 8 h). Ten patients (Group 1) with respiratory arrest underwent emergency intubation; 90 surgical patients (Group 2) underwent anesthesia with endotracheal intubation. Indirect laryngoscopy was performed in 59 symptomatic patients. Abnormal CT findings were present in 86 out of 100 patients. CT irregularities, which included tears, scars and small laryngoceles, were noted on indirect laryngoscopy in 59 symptomatic patients. The laryngeal damage following endotracheal intubation is surprisingly high.

Magnetic resonance imaging (MRI) in patients with complex partial seizures and normal computerized tomography (CT) scan

Magnetic resonance imaging (MRI) examination was performed in 18 patients with complex partial seizures (CPS) of long duration, who had normal computerized tomographic (CT) scans of the brain. Small MRI abnormalities correlating with the location of the epileptogenic focus in the EEG were demonstrated in 4 cases. The findings with strong signals were better demonstrated in the coronal view with longer time to echo (TE). In one patient, a lower signal lesion was documented, which was better visualized in the axial view with shorter TE. Patients with CPS should be subjected to MRI examinations with coronal and sagittal planes, using short and long TE in each slice. This method minimizes the chance for missing pathology.

Focal epileptic activity following intravenous contrast material injection in patients with metastatic brain disease.

Four patients with metastatic brain disease were referred for computed tomographic (CT) examination with contrast material injection. Within 2 to 4 minutes after the intravenous administration of water soluble contrast agent, focal epileptic activity occurred. The seizures became generalised in two of the patients who later died following status epilepticus. In the other two patients the focal seizures correlated with the localisation of the metastatic mass lesions. None of the patients had a previous history of epilepsy.

An association between imaging and acute posttraumatic ear bleeding with trismus

OBJECTIVES Computed tomography findings for each of 94 patients with unilateral ear bleeding and trismus correlated with either comminuted temporal bone fracture (26 cases) or bilateral temporomandibular joint fracture (68 cases). STUDY DESIGN Ninety-four patients with post-traumatic unilateral ear bleeding and 10 asymptomatic adults underwent coronal computed tomography examinations of their temporomandibular joints. Of these, 26 patients with intact temporomandibular joints underwent axial computed tomography of the temporal bones. For 23 of the 94 symptomatic patients, computed tomography was the final imaging procedure; for the other 71 symptomatic patients, it was the first imaging procedure. Quantifications of the radiation dose and the per-patient cost of imaging were performed. Measurement of the maximal mandibular movements in vertical and horizontal directions was performed clinically in the 10 asymptomatic adult control subjects and in the 94 patients with trismus and ear bleeding. RESULTS Ten control subjects had maximal opening values of 40 mm or more, and horizontal movement exceeded 24 mm. In 68 symptomatic patients, coronal computed tomography demonstrated bilateral fracture: there was bilateral high condylar fracture in 35 patients, and there was ipsilateral to the bleeding high condylar fracture with contralateral subcondylar fracture dislocation in 33 patients. Axial computed tomography scans in 26 symptomatic patients with intact temporomandibular joints demonstrated comminuted petrous bone fracture ipsilateral to the ear bleeding. CONCLUSIONS Patients with post-traumatic ear bleeding associated with trismus should first be evaluated by computed tomography. Any other initial procedure doubles the radiation dose as well as the cost of the imaging.

Magnetic resonance imaging in patients with progressive myelopathy following spinal surgery.

Thirty one patients with insidious progressive myelopathy 2 to 8 years following surgery of the cervical spine were subjected to magnetic resonance imaging (MRI). In 15 patients operated on for vascular malformations or intramedullary tumours, syringomyelia and cystic lesions of the spinal cord were shown. Seven of these patients also showed a combination of a recurrent tumour and spinal atrophy. Out of 16 patients who had surgery for herniated disc or spinal stenosis of the cervical spine, four had syringomyelia and 12 had spinal cord atrophy. There was no syringomyelia in the 12 patients submitted to MRI prior to surgery.

Magnetic resonance imaging of the temporo-mandibular joint and meniscus dislocation

A preliminary study of the temporo-mandibular joint (TMJ) by magnetic resonance imaging (MRI) was performed. Ten asymptomatic volunteers with no clinical history of TMJ disorder and five patients with a recent history of trauma to the TMJ were examined using a special surface coil. The meniscus, which is only slightly brighter than the surrounding tissue, gave a high signal and was demonstrated very clearly in its normal position in the controls and shown to be dislocated in the post-trauma cases. Four criteria for identification of the temporo-mandibular meniscus were established in the normal cases and compared with the findings in the pathological cases.