Jan Brismar

Persistent hypoglossal artery, diagnostic criteria. Report of a case.

After a brief racapitulation of the embryology of the vertebrobasilar arterial system, one new case (the 26th) with a persistent hypoglossal artery is presented. As in this case a well developed posterior communicating artery existed, new diagnostic criteria have been formulated.

Spontaneous Carotid-Cavernous Fistulas Phlebographic Appearance and Relation to Thrombosis

Six consecutive cases with spontaneous carotid-cavernous fistulas were examined with orbital phlebography and bilateral carotid angiography. One of the fistulas was fed only by one internal carotid artery, 1 only by the accessory meningeal branch of the maxillary artery, while 4 were supplied by external as well as internal carotid arteries. The findings at phlebography seem to be characteristic. Thrombosis was demonstrated in all 6 cases. Different mechanisms for the genesis of thrombosis in association with carotid-cavernous fistulas are proposed. Alternative therapy methods are discussed.

Aseptic thrombosis of orbital veins and cavernous sinus. Clinical symptomatology.

Occlusion or thrombosis of the superior ophthalmic vein or of the cavernous sinus is an unspecific finding that may be secondary to different disorders such as tumours of the skull base or nasopharynx. Sometimes, however, no underlying disorder is found in spite of an extensive clinical and radiological evaluation. Eight such cases are here presented. Similar cases have previously been described, both as examples of the Tolosa‐Hunt syndrome and as aseptic cavernous sinus thrombosis. The literature on these two disorders is reviewed and different diagnostic criteria discussed.

Spontaneous carotid-cavernous fistulas. Clinical symptomatology.

The symptomatology in six cases with spontaneous carotid‐cavernous fistulas is discussed. All six patients presented with exophthalmos, dilated veins, pain and restriction of ocular movements. In four patients a bruit was found objectively as well as subjectively, four patients exhibited an increase of the intraocular pressure and in three cases vision was impaired. Of special interest is the finding that discrete symptoms such as venous congestion and slight pain appeared early in the course of the disease in all patients, and that in some of the patients an increase in intraocular pressure as well as disturbances in ocular motility were diagnosed long before the appearance of the exophthalmos.

Orbital Phlebography: II. Anatomy of Superior Ophthalmic Vein and its Tributaries

At orbital phlebography the diagnosis has been based largely upon changes in the appearance of the superior ophthalmic vein, except for those comparatively rare cases, where tumor veins or venous malformations are demonstrated. It is then surprising that little information is to be gained from the literature concerning the normal variations in the course of the vein, if the course is similar in both orbits, the normal width of the vein and if this be related to technical factors at the examination. The reports available are partly contradictory, and it is also uncertain what diagnostic value is attached to an incomplete demonstration of the vein. As orbital phlebography is gaining increasing interest the present investigation was undertaken to acquire a deeper knowledge of the anatomy of the superior ophthalmic vein and its variations as a basis for the differentiation between normal and pathologic conditions.

Computer tomography in superior sagittal sinus thrombosis.

Three angiographically confirmed cases and one possible case of aseptic superior sagittal sinus thrombosis had CT findings ranging from apparently normal to single or even bilateral multiple intracerebral hemorrhages surrounded by low-attenuation regions. The latter finding, in particular, suggests a possible superior sagittal sinus thrombosis.

Computer tomography as the primary radiologic procedure in acute subarachnoid hemorrhage.

CT was performed in 149 patients with acute subarachnoid hemorrhage and clinical findings consistent with an aneurysm rupture, and was found informative in most cases when performed within one week after the hemorrhage. CT disclosed in 29 per cent of cases other causes for the hemorrhage than a ruptured aneurysm (intracerebral hemorrhage, tumor, trauma, infarct) and an extensive angiographic evaluation could be omitted. In those patients where the hemorrhage was caused by an aneurysm rupture, the distribution of extravasated blood in the subarachnoid space and the brain parenchyma usually indicated the aneurysm location--angiography could thus be restricted to the proper vessel. These capabilities of CT are sufficient to economically motivate its routine use as the primary investigation in cases with an acute subarachnoid hemorrhage.

Thrombosis of the intraorbital veins and cavernous sinus.

Eight cases with phlebographic appearances consistent with aseptic thrombosis of the cavernous sinus or of the posterior part of the superior ophthalmic vein are presented. The clinical course is briefly described and the phlebographic findings and possible differential diagnoses discussed. Even if recent methods may obviate the need for phlebography in the demonstration of orbital tumors in certain cases, the possibility of intraorbital or cavernous sinus thrombosis constitutes an important indication for phlebography.

Complications of orbital and skull base phlebography.

Two complications, one in association with frontal vein phlebography and one in association with inferior petrosal sinus phlebography, are presented. Possible mechanisms for complications are discussed. It is concluded that a significant risk exists in association with inferior petrosal sinus phlebography, particularly in association with vascular disorders of the skull base, while the risk in association with orbital phlebography after frontal vein puncture is minimal if compression of the jugular veins is omitted.

Orbital Phlebography: III. Topography of Intraorbital Veins

The value of orbital ,phlebography in cases with unilateral proptosis is well established (e.g. LOMBARDI & PASSERINI 1969, LLOYD 1970, HANAFEE 1972, HAYE et colI. 1970, BOUDET 1955, ARON-RoSA et colI. 1966). The diagnosis of a lesion is based mainly on changes in the superior ophthalmic vein. Displacement of this vessel will indicate not only the presence of an expansive lesion, but also its location (e.g. SCHOBER & BENDER 1968, HAYE et colI. 1970). In cases of major displacement of this vein, few diagnostic problems exist, but when there is only a small difference between the location of the vein in the two orbits, the diagnosis of tumor is hazardous because a significant asymmetry between the two sides may be a normal condition (BRISMAR 1974 b). Since even small orbital veins are almost constantly demonstrated by the use of the present authors technique (BRISMAR 1974 a), it seemed reasonable to aim at a more certain diagnosis by also analyzing possible displacements of these veins. A prerequisite, then, is a deeper knowledge of the normal phlebographic appearance of these veins and their variations than is available at present. In the past this aspect has not gained much attention in reports on orbital phlebography. . From the Section on Neuroradiology (Director: S. Cronqvist), Department of Diagnostic Radiology (Director: Prof. O. Olsson), University Hospital, S-221 85 Lund, Sweden. Submitted for publication 21 December 1973,