Stephen A. Kieffer

Intracerebral venous angioma.

Intracerebral venous angioma is a rare congenital vascular malformation of the brain. Three cases are reported, all of which had strikingly similar angiographic findings in the venous phase, viz., a local network of small medullary veins which converge centrally into a single large venous channel which courses transcerebrally to reach the superficial venous system. No gross abnormalities are seen in the arterial phase with the usual techniques. However, magnification delineated enlarged arterial branches supplying the periphery of the malformation in 2 of the 3 cases. A poorly marginated homogeneous blush and early filling of the draining veins were also seen in these 2 patients. The findings in the venous phase agree with those described in previous isolated case reports and appear to be highly suggestive of this rare malformation.

Correlation of computed tomography, gray scale ultrasonography, and radionuclide imaging of the liver in detecting space-occupying processes.

The abilities of computed tomography (CT; scanning time=2.7 min), gray scale ultrasonography, and radionuclide imaging to detect and characterize space-occupying processes in the liver were compared. A numerical rating scale which emphasized detection abilities resulted in ultrasonography scoring 3.5 CT 3.2, and radionuclide imaging 2.9. CT resulted in no false positives and 6 false negatives, caused mainly by motion artifacts. The simplest technique, radionuclide imaging, also had the smallest number (2) of false negatives; it is therefore recommended as the screening procedure of choice. Sonography or CT should be done for those patients with a prior suspicious finding.

Acute Toxic Leukoencephalopathy: Potential for Reversibility Clinically and on MRI With Diffusion-Weighted and FLAIR Imaging

OBJECTIVE Toxic leukoencephalopathy may present acutely or subacutely with symmetrically reduced diffusion in the periventricular and supraventricular white matter, hereafter referred to as periventricular white matter. This entity may reverse both on imaging and clinically. However, a gathering together of the heterogeneous causes of this disorder as seen on MRI with diffusion-weighted imaging (DWI) and an analysis of their likelihood to reverse has not yet been performed. Our goals were to gather causes of acute or subacute toxic leukoencephalopathy that can present with reduced diffusion of periventricular white matter in order to promote recognition of this entity, to evaluate whether DWI with apparent diffusion coefficient (ADC) values can predict the extent of chronic FLAIR abnormality (imaging reversibility), and to evaluate whether DWI can predict the clinical outcome (clinical reversibility). MATERIALS AND METHODS Two neuroradiologists retrospectively reviewed the MRI examinations of 39 patients with acute symptoms and reduced diffusion of periventricular white matter. The reviewers then scored the extent of abnormality on DWI and FLAIR. ADC ratios of affected white matter versus the unaffected periventricular white matter were obtained. Each patients clinical records were reviewed to determine the cause and clinical outcome. Histology findings were available in three patients. Correlations were calculated between the initial MRI markers and both the clinical course and the follow-up extent on FLAIR using Spearmans correlation coefficient. RESULTS Of the initial 39 patients, seven were excluded because of a nontoxic cause (hypoxic-ischemic encephalopathy [HIE] or congenital genetic disorders) or because of technical errors. In the remaining 32 patients, no correlation was noted between any of the initial MRI markers (percentage of ADC reduction, DWI extent, or FLAIR extent) with the clinical outcome. Three patients had histologic correlation. However, moderate correlation was seen between the extent of abnormality on initial FLAIR and the extent on follow-up FLAIR (r = 0.441, p = 0.047). Of the 13 patients who underwent repeat MRI at 21 days or longer, the reduced diffusion resolved in all but one. Significant differences were noted between ADC values in affected white matter versus unaffected periventricular white matter on initial (p < 0.0001) but not on follow-up MRI (p = 0.13), and in affected white matter on initial versus follow-up (p = 0.0014) in those individuals who underwent repeat imaging on the same magnet (n = 9), confirming resolution of the DWI abnormalities. CONCLUSION Acute toxic leukoencephalopathy with reduced diffusion may be clinically reversible and radiologically reversible on DWI, and may also be reversible, but to a lesser degree, on FLAIR MRI. None of the imaging markers measured in this study appears to correlate with clinical outcome, which underscores the necessity for prompt recognition of this entity. Alerting the clinician to this potentially reversible syndrome can facilitate treatment and removal of the offending agent in the early stages.

Reconstitution of Vertebral Height in Histiocytosis X: A Long-Term Follow-up

Ten children with histiocytosis X with vertebral column involvement were followed through the natural course of the disease. The characteristic roentgen findings were (1) a variable degree of collapse of a vertebral body, (2) no thinning or thickening of the adjacent intervetebral discs, and (3) absence of a soft-tissue mass. The natural history was one of restoration of varying degree in vertebral height. This could occur even though there had been almost complete collapse (vertebra plana) at the onset of the disease. Neurological complications were rare and the eventual outcome of all the patients did not appear to be affected by the type of treatment given.

Intradural herniation of lumbar intervertebral discs.

A case of intradural rupture of a lumbar intervertebral disc is reported, and the literature is reviewed. The majority of intradural disc herniations occur at the L4-5 level. These patients usually have neurologic deficits more severe than those found in the much more common extradural disc herniations. The myelographic picture varies from an irregularly marginated intradural lesion overlying the disc space to a complete block. The common factor allowing intradural disc herniation is probably dense adhesions between the dura and the posterior longitudinal ligament, preventing the more common lateral extradural disc herniation. Intradural disc herniation should be included in the differential diagnosis of lumbar intradural lesions causing nerve root or cauda equina compression.

Orbital Dysplasia in Neurofibromatosis

A dysplasia of the bony walls of the orbit is one of the congenital anomalies associated with generalized neurofibromatosis (1–6). Orbital dysplasia may be mistaken clinically and radiographically for neoplasm or chronic subdural hematoma within the middle cranial fossa unless its characteristic plain film and angiographic findings are appreciated. Plain Skull Film Findings The plain skull film findings of 7 patients with neurofibromatosis and orbital dysplasia, ranging in age from eighteen months to fifty-seven years, are summarized in Table I. All 7 showed obvious stigmata of neurofibromatosis, e.g., cafe au lait spots, subcutaneous tumors, or skeletal anomalies. The major presenting complaint in all cases was pulsating exophthalmos. Radiographs of the skull in all 7 patients demonstrated a dysplastic sphenoid bone complex. This consists of hypoplasia of the greater and lesser sphenoid wings, resulting in (a) elevation of the lesser sphenoid wing, (b) widening of the superior orbital fissure, and (c) la...

Contrast Agents for Myelography: Clinical and Radiological Evaluation of Amipaque and Pantopaque

The diagnostic quality and side effects of Amipaque and Pantopaque as myelographic contrast agents were compared prospectively using the identical protocol in 167 cases (117 Amipaque, 50 Pantopaque). Good ratings were attained in 74% of Amipaque and 76% of Pantopaque examinations. Demonstration of nerve rootlets in the cauda equina and filling of lumbar root sleeves were superior with Amipaque. Amipaque more easily demonstrated the high posterior cervical subarachnoid space and the anterior and posterior margins of the cervical spinal cord. The incidence of postmyelographic headache was 38% with Amipaque and 32% with Pantopaque. Nausea and vomiting were more common with Amipaque. Two patients experienced grand mal seizures after examination sith Amipaque.

Radiographic and angiographic characteristics of pulmonary veno-occlusive disease.

Abstract Pulmonary veno-occlusive disease (PVOD) is an uncommon cause of fatal pulmonary hypertension and cor pulmonale. The radiographic findings in 11 previously reported cases and 2 new cases include progressive right ventricular enlargement with increasing prominence of the central pulmonary vasculature and the development of peripheral septal lines (Kerley B lines). Pulmonary arteriography revealed dilated patent pulmonary arteries, a markedly prolonged circulation time, and a normal left atrium and pulmonary veins.

Intraosseous Leptomeningeal Cysts of the Posterior Cranial Fossa

Post-traumatic leptomeningeal cysts involving the occipital bone are intraosseous lesions which do not erode through the outer table, in contradistinction to leptomeningeal cysts elsewhere in the calvaria. In two of four reported cases, communicating hydrocephalus was associated with the intraosseous cyst. The clinical and radiological findings suggest that intraosseous leptomeningeal cyst of the posterior fossa represents a distinct entity. Resection of the cyst and closure of the dural defect may be less important than treatment of the communicating hydrocephalus.

The borderline scinticisternogram.

Scinticisternography using 99mTc albumin was performed in 55 patients with progressive dementia. Persistent reflux of radioactivity into cerebral ventricles was found in 17 but was associated with block to subarachnoid flow over the cerebral surfaces in only 7. Transient ventricular reflux was found in 11 patients, none of whom had a block. Flow over cerebral surfaces in patients with ventricular reflux suggests that if there is an obstructive element in such cases, it is incomplete and probably coexistent with variable degrees of cerebral atrophy. There was no clear correlation between clinical assessment of likelihood of normal pressure hydrocephalus and scinticisternographic pattern nor any significant correlation between findings at pneumoencephalography and scinticisternographic pattern.