Subdural haematoma in patients with spontaneous intracranial hypotension

The incidence and clinical relevance of subdural haematoma (SDH) in patients with spontaneous intracranial hypotension (SIH) remain undetermined. We reviewed 40 consecutive SIH patients (18 female, 22 male) in a tertiary hospital. Eight (20%) of them had SDH and nine (23%), non-haemorrhagic subdural collections. The presence of SDH was associated with higher frequencies of male gender, recurrence of severe headache and neurological deficits. Outcomes were satisfactory after supportive care or epidural blood patches except for one SDH patient, who developed transtentorial herniation resulting in Duret haemorrhage and infarctions of bilateral posterior cerebral artery territories. In conclusion, subdural fluid collections were common in patients with SIH. SDH was associated with headache worsening or neurological deficits. Patients with SDH generally recovered well; however, serious sequela might occur.     

Heavily T2-weighted MR myelography in patients with spontaneous intracranial hypotension: a case-control study

We performed whole-spine heavily T2-weighted magnetic resonance (MR) myelography using a single-shot fast spin-echo pulse sequence in 17 patients (8 M/9 F) with spontaneous intracranial hypotension (SIH) to detect abnormal cerebrospinal fluid (CSF) collections. In addition, a group of age- and sex-matched controls were recruited. Follow-up MR myelography was also done at 3 weeks. MR myelography showed three kinds of abnormal CSF collections in 15 patients with SIH (88%): epidural fluid collection (n = 15, 88%), C1-2 extraspinal collections (n = 6, 35%) and CSF collections along nerve roots in the lower cervical or upper thoracic spines (n = 6, 35%). One patient (6%) showed a meningeal diverticulum. In contrast, none of the controls showed these findings. Overall, MR myelography results helped in early diagnosis of SIH in four (24%) patients whose initial brain MRIs failed to show typical SIH findings. Follow-up MR myelography results were compatible with the clinical changes with kappa statistics of 0.52 and an agreement rate of 76%. Our study showed heavily T2-weighted MR myelography provided a rapid, non-invasive and high yield method to diagnose and follow-up patients with SIH. Whether the CSF collections along the nerve roots represent the ongoing leakage sites warrants further study.     

Olfactory auras in patients with temporal lobe epilepsy

PURPOSE: To investigate olfactory auras in patients with temporal lobe epilepsy (TLE). METHODS: We reviewed medical records of 217 Chinese patients who underwent temporal lobectomy for medically intractable TLE between 1987 and 1998 in Taiwan. Patients with olfactory auras asked for detailed characteristics of their auras. RESULTS: In all, 12 (5.5%) patients had olfactory auras, seven men and five women. All patients except one described and characterized the unpleasant olfactory auras. Olfactory auras were usually combined with other auras, most frequently sensations of epigastric rising, nausea, and fear. Association with gustatory hallucination was uncommon, in only one patient. On neuroimaging study, 11 patients had structural lesions involving the mesial temporal structures, two exclusively involving the amygdala. Histologic diagnosis included gliosis of the mesial temporal regions in seven (58.3%) patients, neoplasm in four (33.3%) patients, and arteriovenous malformation in one patient. Postoperatively, eight patients were seizure free. Three patients had rare seizures; however, none reported residual olfactory auras. CONCLUSIONS: Olfactory auras are infrequent in TLE. In this study, mesial temporal sclerosis is the most common etiology rather than tumors. Mesial temporal structures, especially the amygdala, may play important roles in the genesis of olfactory auras.     

Three-Dimensional Contrast-Enhanced Magnetic Resonance Angiography of Carotid Artery after Stenting

PURPOSE: This study presents 3-dimensional, contrast-enhanced, magnetic resonance (MR) angiographic appearances of the carotid artery after stenting. METHODS: The authors reviewed contrast-enhanced MR angiograms of 18 carotid arteries in 13 patients. These arteries were not stenotic or occluded in the stented segment, as shown on carotid angio-grams (11 patients) or carotid Doppler images (2 patients) obtained later. RESULTS: Five patients had 1 stent in each of their bilateral carotid arteries. One patient with 1 stent in 1 artery underwent the examination twice with different MR coils. Different artifact patterns were found in 19 carotid-stent examinations. Type 1a involved short segments of false narrowing or false focal occlusion at both ends of the stent (n = 12); the carotid artery in the stented segment between the ends was normal. Types 2a and 2b occurred along the stented segment of the artery between the 2 ends of the stent. Type 2a was milder, with segmental faint signal intensity or luminal stenosis in the entire length of the stented segment (n = 5). Type 2b was total loss of luminal signal intensity over the whole length of the stented segment (n = 2). Last, type 1b was a band of hyperintensity at the ends of type 2a or 2b artifacts. Types 1a and 1b were due to susceptibility effect, and types 2a and 2b were from radio-frequency shielding effect. Both of these effects were identified in MR angiogram of nitinol stents and stainless steel stents. CONCLUSION: Awareness of these artifacts is essential to prevent misdiagnosis.     

Diameter of the superior ophthalmic vein in relation to intracranial pressure

BACKGROUND AND PURPOSE: Bilateral engorged superior ophthalmic veins (SOV) have been reported in patients with diffuse brain swelling. We investigated the relationship between the diameter of the SOV on brain MR images and the intracranial pressure (ICP). METHODS: We reviewed the medical records of neurologic inpatients who had undergone both MR imaging of the brain and lumbar puncture. MR imaging had to have been performed before lumbar puncture, and the two studies had to have occurred within 2 days. The diameters of the SOV were measured on coronal contrast-enhanced fat-saturated T1-weighted MR images. For this, the image nearest the rear of the globe of the eye was chosen. RESULTS: Sixty-nine patients (32 male, 37 female; mean age, 46 years +/- 19) were included. The average diameters of the SOV and the ICP were positively correlated (r = 0.58, P <.001), if an SOV diameter of <1 mm was treated as 0.5 mm for calculations. In patients with increased ICP (CSF pressure >200 mm H(2)O), SOV diameters were larger than those of patients with a normal CSF pressure (3.0 vs 1.6 mm, P <.001). Frequencies of increased ICP were 3% among patients with an average SOV diameter of 0.5-1 mm, 15% for 1.5-2 mm, and 58% for 2.5-5 mm (P <.001). CONCLUSION: This study showed that the SOV diameter, determined on the basis on MR imaging, was positively correlated with ICP. Dilatation of the SOV should alert physicians to the possibility of increased ICP.     

Carotid blowout syndrome in patients with head-and-neck cancers: reconstructive management by self-expandable stent-grafts

BACKGROUND AND PURPOSE: Some reports of reconstructive management of carotid blowout syndrome (CBS) with stent-grafts are promising, but some are unfavorable. This study sought to evaluate the hemostatic efficacy, safety, and outcome of reconstructive, endovascular stent-graft placement in patients with head-and-neck cancers in association with CBS. METHODS: Eight patients with head-and-neck cancers with CBS were treated with self-expandable stent-grafts. We evaluated the initial hemostatic results, complications, and outcomes by assessing the clinical and imaging findings. RESULTS: Immediate hemostasis was achieved in all patients. Initial complications included stroke in 1 patient and asymptomatic thrombosis of the carotid artery in 2 patients. Delayed complications included rebleeding, delayed carotid thrombosis, and brain abscess formation. Rebleeding was noted in 4 patients and was successfully managed with a second stent-graft and embolization in 2 of them. Delayed carotid thrombosis with follow-up after 3 months was found in 3 patients, 1 of whom had associated brain abscesses. CONCLUSION: Although stent-grafts achieved immediate and initial hemostasis in patients with head-and-neck cancers and CBS, long-term safety, stent patency, and permanency of hemostasis appeared unfavorable. This treatment may be for temporary or emergency purposes rather than serving as a permanent measure. We suggest its applications in patients with acute CBS that precludes performance of an occlusion test, as well as when carotid occlusion poses an unusually high risk of neurologic morbidity. We also propose prophylactic antibiotic treatment and combined embolization of pathologic vascular feeders to improve outcomes.     

Comparisons between heavily T2-weighted MR and CT myelography studies in two patients with spontaneous intracranial hypotension

Our previous study demonstrated that heavily T2-weighted magnetic resonance (MR) myelography could successfully detect abnormal cerebrospinal fluid (CSF) collections in patients with spontaneous intracranial hypotension (SIH); however, its ability to demonstrate ongoing CSF leakage sites is uncertain. Currently, computed tomographic (CT) myelography is still considered the study of choice for such a purpose. In this study, we compared the results of the two imaging modalities in two patients with SIH. CSF leakages, such as C1-2 extraspinal collections, CSF along nerve root sleeves, and epidural fluid collections were noted on both studies with minor discrepancies. CSF collection along nerve root sleeves demonstrated by MR myelography was the most likely ongoing leakage site in comparison with CT myelography. Targeted epidural blood patches in both patients resulted in complete headache resolution. Non-invasive, non-contrasted and time-saving MR myelography is a promising study for patients with SIH. Further large-scale validation studies are needed.     

Patients with head and neck cancers and associated postirradiated carotid blowout syndrome: endovascular therapeutic methods and outcomes

PURPOSE: This study retrospectively evaluated the technical and hemostatic outcomes of reconstructive and deconstructive endovascular management in patients with head and neck cancers associated with carotid blowout syndrome (CBS). METHODS: Twenty-four patients with head and neck cancers with CBS involving the main trunk of carotid artery underwent endovascular therapy. This included reconstructive management with self-expandable stent grafts to preserve the diseased carotid artery in 11 patients and deconstructive management with balloons, coils, or acrylic adhesives to occlude the diseased carotid artery in 13 patients. Based on clinical severity and therapeutic priority, we classified CBS in our patients into two groups: acute or impending and threatened. The angiographic severity was graded from 0 to 3. Evaluation of technical outcome included technical success, initial and delayed complications, and patency of stent graft in the reconstructive group. The hemostatic outcome was evaluated by immediate hemostatic result, rebleeding, and duration of hemostasis. Sex, age, clinical and angiographic severities, local wound complications, and location of the pathologic lesion were examined as predictors of the technical and hemostatic outcomes of endovascular management by using Cox regression method. RESULTS: Technical success and immediate hemostasis were achieved in all patients of both groups. Initial complications during the procedures were encountered in four patients (36.4%) who underwent reconstructive management and in one patient (7.7%) who underwent deconstructive management (P = .142). Delayed complications during the follow-up were seen in one patient (9.1%) with reconstructive management and one patient (7.7%) with deconstructive management (P > .99). Rebleeding occurred in five patients (45.5%) in the reconstructive management group and in three patients (23.1%) in the deconstructive management group (P = .659). The mean duration of hemostasis after initial reconstructive and deconstructive management was 4.0 +/- 8.1 and 8.5 +/- 10.1 months, respectively (P = .249). Rebleeding was noted in 7 of 11 patients (63.6%) with acute CBS and in 1 of 13 patients (7.7%) with impending and threatened CBS (P = .008). CONCLUSION: There is no significant difference in technical and hemostatic outcomes between the reconstructive and deconstructive endovascular management methods. Hemostatic results were influenced by clinical severity. The rebleeding rate is higher in patients with advanced and acute clinical severity.     

Aspergillosis of the paranasal sinuses

Summary The CT appearances of 13 cases of pathologically proven aspergillosis involving paranasal sinuses were reviewed. Symptoms included rhinorrhea, nasal obstruction, headache, facial pain and foul smell from the nose. At operation, these lesions appeared yellowish, brownish, grey or black in colour, and contained dirty or muddy material. Microscopic examination of the tissue removed showed anAspergillus ball with chronic inflammation but without invasion of the nasal or sinus mucosa in 6 cases, and tissue invasion with necrosis and inflammation in 7. The structures involved, in order of frequency, were: maxillary sinus, nasal cavity, ethmoid sinus, orbit and cavernous sinus. The orbit was involved in 2 cases, therefore categorized as invasive; the other 11 cases were non-invasive as judged by CT. Calcification was seen in the lesions of 9 cases. In most cases the adjacent bony structures showed areas of erosion and sclerosis. Aspergillosis should be suspected in the presence of a mass in the paranasal sinuses or nasal cavity with calcification within it, which may not appear solid or dense and is separate from the walls of the sinus.