Orlando Ortiz

Parietal Occipital Edema in Hypertensive Encephalopathy: A Pathogenic Mechanism

Eight patients with hypertensive encephalopathy from diverse etiologies developed cerebral edema in the vertebrobasilar distribution which resolved after blood pressure was lowered. Parietal occipital edema is a recognized feature of hypertensive encephalopathy. The explanation for this regional pathological variation in hypertensive encephalopathy remains undefined. Some evidence suggests that sympathetic innervation of the anterior cerebral vasculature may be protective, and conversely, the relative lack of sympathetic innervation in the vertebrobasilar vasculature may predispose the parietal occipital region to the development of cerebral edema in hypertensive encephalopathy.

CONTEMPORARY MANAGEMENT OF CEREBROSPINAL FLUID RHINORRHEA

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeons preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.

Postoperative Magnetic Resonance Imaging with Titanium Implants of the Thoracic and Lumbar Spine

Within recent years, the technologies of radiological imaging and spinal instrumentation have exponentially increased. New methods of preoperative imaging, that is, magnetic resonance imaging (MRI) and computed tomography, have allowed for a better understanding of surgical pathology. Such an understanding is likely to lead to a more successful surgical experience, which certainly is the case with spine surgery with instrumentation. However, after implantation of most instrumentation, imaging is greatly impaired. Metallurgic advancements in titanium were sought to reduce postoperative imaging problems. The purpose of this study is to assess the presence and extent of artifacts seen on postoperative MRI scans in patients with titanium spinal implants. Six patients, four with degenerative spine disease and two with neoplasms, had thoracic and/or lumbar spinal fixation performed with titanium instrumentation. All patients underwent postoperative conventional MRI with the use of T1-weighted, T2-weighted, and gradient-echo sequences. The scans and individual sequences were then analyzed for image quality. A progressive and significant increase in imaging artifact related to the titanium spinal instrumentation was observed on the T1-weighted, T2-weighted, and gradient-echo sequences. Titanium spinal instruments do not allow optimal postoperative imaging on conventional MRI scanners.

Vascular contrast enhancement in Lhermitte-Duclos disease: case report

We report a patient with surgically proven Lhermitte-Duclos disease. The radiologic and pathologic features of this cerebellar lesion are reviewed, including the newly reported presence of vascular contrast enhancement within the mass.

Congenital nasal pyriform aperture (bony inlet) stenosis

Congenital nasal pyriform aperture stenosis should be considered in the differential diagnosis of infants with nasal airway obstruction. It can occur as an isolated anomaly or it can be associated with other congenital anomalies. A history of cyclical respiratory distress and cyanosis often associated with feeding and relieved by crying is characteristic. On examination, the nasal airway is narrowed anteriorly. CT is the study of choice to make the diagnosis and rule out other causes of nasal obstruction. Conservative management is recommended, sometimes with the use of a McGovern nipple for feeding. Severe cases or those in which conservative management fails should be considered for surgery.

Transient enlargement of an intracranial aneurysm during pregnancy: Case report

BACKGROUND The association of intracranial aneurysm and pregnancy is uncommon. Hemodynamic stress plays an important role in the growth of aneurysms. METHODS The authors report the case of an enlarging cavernous carotid aneurysm in a pregnant 15-year-old young woman. RESULTS The aneurysm was initially diagnosed prior to the patients pregnancy by both cross-sectional imaging and cerebral angiography. Further imaging evaluation was required during pregnancy, which demonstrated significant enlargement of the aneurysm. Following delivery, the lesion decreased in size. CONCLUSIONS We review potential factors associated with pregnancy that may increase hemodynamic stress and influence aneurysm growth. Additionally, the management of pregnancy-related intracranial aneurysms is discussed.

Analysis of Breakthrough Pain in 50 Patients Treated with Intrathecal Morphine Infusion Therapy

Fifty patients with intractable benign pain were treated with intrathecal morphine (IT-MS) infusion therapy. Median follow-up was 39 months (range 5-70). Breakthrough pain was reported in 45 (90%) patients in 75 outpatient clinic events. A diagnostic algorithm was developed to evaluate and efficiently treat these patients. A programmed bolus (50% of daily dose) identified that 50 (67%) breakthrough events where due to partial tolerance to the IT-MS. Radiographic survey of the catheters identified malfunctions in 11 patients. Attempts to withdraw CSF from the side-port demonstrated obstruction in 7 due to kinking not seen on X-rays. Side-port myelography demonstrated scarring that obstructed the flow of morphine to the spinal cord in 2 patients. Benefits were regained after all surgical catheter corrections. In total, partial tolerance was seen in 23 patients (46%) during 50 (67%) breakthrough events, 15 patients (30%) required 22 catheter revisions during 27% of breakthrough events and 2 patients had progressive disease. True tolerance was encountered in only 5 patients (10%) during 5 (7%) breakthrough pain events.

Stroke Due to a Traumatic Vertebral Artery Dissection in a Girl

pendently with eyes open and was able to walk only with support. A complete blood count, serum lactic acid, routine chemistries, and echocardiography were normal. Her coagulation profile was normal, including platelet counts, prothrombin time, antithrombin III, protein C, and antilupus anticoagulant. A cranial CT scan showed mild hydrocephalus and a large, lucent inferior vermian cerebellar lesion that extended

Cerebral amyloid angiopathy presenting as a nonhemorrhagic, infiltrating mass.

We present a case of biopsy-proven cerebral amyloid angiopathy mimicking a unilateral, nonhemorrhagic, infiltrating, intra-axial mass on MRI. The patient was treated with steroids, with clinical improvement and significant resolution of the MRI abnormalities.

Size of the corpus callosum in cerebral palsy.

It has been suggested that the size of the corpus callosum may have diagnostic significance in cerebral palsy, although this relationship is incompletely defined. Ninety‐one patients with cerebral palsy had been studied by magnetic resonance imaging in the 5‐year period from 1990 to 1994. Fifty‐seven of these 91 patients had a technically appropriate midsagittal magnetic resonance image for quantitative morphometric analysis. The ratio of the area of the corpus callosum to the area of the supratentorial brain was compared to published age‐ and gender‐specific norms. Imaging findings were correlated with clinical history and cause of cerebral palsy. The corpus callosum was of normal size in 43 patients and more than 2 standard deviations below the mean in 14 patients. The causes for cerebral palsy included hypoxic ischemic encephalopathy (32), cerebral dysgenesis (8), and porencephalic strokes (6); the etiology could not be established in 11 patients. The size of the corpus callosum was highly correlated with the cause of cerebral palsy, such that all patients with cerebral dysgenesis had hypoplasia of the corpus callosum (one‐sided z test, p < 0.0001). Conversely, the callosum was of normal size in 32 of 38 patients with hypoxic ischemic encephalopathy and porencephalic strokes. The presence of a hypoplastic corpus callosum is highly associated with cerebral dysgenesis as a cause for cerebral palsy.