How to distinguish between bleeding and coagulated extradural hematomas on the plain CT scanning

Summary Four types of extradural hematoma could be separated at examination of the plain CT scan in 54 extradural hematomas. Two major groups appear: the still bleeding hematoma showing either generally low attenuation values of holes, and a coagulated homogeneous type with generally high attenuation values. The attenuation values of the bleeding-liquid part of hematoma — were correlated to hemoglobin concentration in blood, to which clots were not related. Seven extradural hematomas grew and coagulated on repeated preoperative CT scans. In two cases intravenous contrast was given to the bleeding type of hematoma, and the contrast media appeared in holes, but not in areas of high attenuation value. It is easy to distinguish between the different types of hematoma on the plain CT scan, and the separation by eye between the still bleeding and the coagulated extradural hematoma seems reliable.Parts of the paper were presented at the Meeting on Recent Advances in Neurotraumatology, Edinburg, 1982     

Computed-tomography of bilateral isodense chronic subdural hematomas

Summary While unilateral chronic isodense subdural hematomas as a result of indirect signs of a space-occupying lesion are easily recognizable on computed tomography (CT) and clearly diagnosed on the angiogram, bilateral chronic isodense subdural hematomas may cause considerable difficulty. In two cases with CT false negative findings we observed, retrospectively, significant small cellae mediae and also the main part of the anterior horns sharply pointed and approaching one another. Three further cases showed the same ventricular configuration, which we called hare's ears sign. This sign together with clinical data is always suspicious of chronic bilateral isodense subdural hematomas and carotid angiography is indicated. Other possible signs are: subtle midline shift if the size of the hematoma varies, changed formation of density of brain tissue, non-appearance of cerebral sulci especially in elderly patients, and eventually the visualization of a membrane after intrevenous injection of contrast material.     

Spinal brucellosis

Summary In this case report, we present a patient with an unusual appearance on vertebral CT due to spinal brucellosis. This cauliflower sign may be specific to this disease.     

Effect of adrenergic receptor ligands on metaiodobenzylguanidine uptake and storage in neuroblastoma cells

The effects of adrenergic receptor ligands on uptake and storage of the radiopharmaceutical [¹²⁵I]metaiodobenzylguanidine (MIBG) were studied in the human neuroblastoma cell line SK-N-SH. For uptake studies, cells were incubated for 15 min with varying concentrations of -agonist (clonidine, methoxamine, and xylazine), -antagonist (phentolamine, tolazoline, phenoxybenzamine, yohimbine, and prazosin), -antagonist (proranolol, atenolol), -agonist (isoprenaline and salbutamol), mixed / antagonist (labetalol), or the neuronal blocking agent guanethidine, prior to the addition of [¹²⁵I]MIBG (0.1 M). The incubation was continued for 2 h and specific cell-associated radioactivity was measured. For the storage studies, cells were incubated with [¹²⁵I]MIBG for 2 h, followed by replacement with fresh medium with or without drug (MIBG, clonidine, or yohimbine). Cell-associated radioactivity was measured at various times over the next 20 h. Propanolol reduced [¹²⁵I]MIBG uptake by approximately 30% (P<0.01) at all concentrations tested, most likely due to nonspecific membrane changes. However, incubation with the other -agonists or antagonists failed to elicit significant reductions in uptake. In contrast, all of the -agonists significantly inhibited uptake (P<0.05); guanethidine >xylazine >clonidine=methoxamine. The -antagonists demonstrated a broad range of inhibition (phenoxybenzamine phentolamine prazosin yohimbine=tolazoline)(P<0.05). The mixed ligand, labetalol, inhibited MIBG uptake in a dose-dependent manner with an apparent IC₅₀ of 0.65 M. The retention studies demonstrated that unlabeled MIBG caused profound self-inhibition (P<0.01). Clonidine produced a modest inhibition of retention and yohimbine had no effect. Labetalol, phenoxybenzamine, guanethidine, and propranolol reduced uptake of [¹²⁵I]MIBG by neuroblastoma cells in culture. Although only labetalol has been reported to cause false-negative MIBG scans, our results suggest that these other drugs have the potential to interfere with MIBG imaging and therapy, particularly at high doses. Adrenergic drugs did not alter cytoplasmic retention of [¹²⁵I]MIBG in neuroblastoma cells but may have potential in tumors such as phenochromocytoma, where granular storage of MIBG has been observed. Inhibition of [¹²⁵I]MIBG retention by unlabeled MIBG supports the use of high specific activity radioiodinated MIBG for both diagnosis and therapy.     

The preparation and composition of HIDA

The compositions of four brands of Tc-HIDA — dimethyl HIDA (Sorin Biomedica), diethyl HIDA (Solco), diethyl HIDA (The Radiochemical Centre), and para-butyl HIDA (Sorin Biomedica) —were investigated at varying times after their preparation from instant kits, by using Sephadex gel column chromatography.Up to three peaks of activity were seen in each chromatogram, representing free reduced technetium, the monocomplex, and the biscomplex of Tc-HIDA respectively.In all cases the free reduced technetium component diminished to reach a plateau at less than 4% of total activity, by 1h. In both brands of diethyl HIDA there was a transformation from the monocomplex to the biscomplex which took about one hour. The rate of this transformation was increased by raising the temperature of incubation, or by agitation during incubation.In the para-butyl HIDA this transformation was again noted, but was incomplete. In the dimethyl HIDA the monocomplex form was not seen.There was no noticeable disintegration of any Tc-HIDA complex up to 6 h.It is suggested that HIDA should be incubated for 1 h after preparation, before use, to achieve a stable composition.     

Measurement of blood flow from first-pass radionuclide angiography: Influence of bolus volume

Fractionation of cardiac output on first-pass radionuclide angiography is a recently described technique for measuring blood flow. In order to determine the influence of bolus volume, splenic blood flow (SBF) and renal blood flow (RBF) were measured from widely differing bolus volumes given in sequence over a period of a few minutes in patients undergoing routine bone scintigraphy with technetium 99m methylene diphosphonate. A bolus volume of 0.5 ml, followed by 20 ml of rapidly delivered saline chaser, was regarded as a gold standard bolus. A 50 ml bolus, but not a 20 ml bolus, resulted in a significant underestimation of both SBF and RBF. Thus, using a left ventricular region of interest to generate an arterial first-pass time-activity curve, RBF from a 50 ml bolus was 58% (SEM 4%) that given by a 0.5 ml bolus, while RBF for a 20 ml bolus was 98% (8%). Corresponding values for SBF were 52% (10%) and 102% (12%). A quality control adjustment did not correct the underestimation given by the 50 ml bolus. Bolus volumes greater than 20 ml give unreliable estimates of organ blood flow by this technique.     

Fogging on T2-weighted MR after acute ischaemic stroke: how often might this occur and what are the implications?

Fogging is the temporary loss of visibility of an infarct on CT which occurs in the subacute phase at about 2 weeks after stroke. It occurs in up to 40% of medium to large infarcts on CT. It is unclear whether or how often fogging occurs on T2-weighted MR, but if it does occur, it can cause underestimation of true infarct size. This study examined the possible frequency and time scale of fogging on T2-weighted MR. We conducted a blinded, independent review of prospectively collected MR scans from patients with symptoms of cortical ischaemic stroke, scanned sequentially up to 7 weeks after stroke. On each scan maximum infarct area was measured, and the infarct extent and swelling were coded on a validated scale. Fogging was suggested by reduced infarct extent between initial and subsequent scans. In 30 patients (with 74 scans) there was some apparent fogging in 50% of patients between 6 and 36 days (median 10 days) after stroke. Reduction in infarct extent on T2-weighted MR which may be attributed to fogging occurs in a significant proportion of patients with cortical infarcts. This may lead to an underestimation of true final infarct extent. This suggests that true infarct extent on T2-weighted MR can probably only be assessed on scans obtained beyond 7 weeks after stroke.     

Sudden unexpected child death associated with ingestion of fluid dish detergent

Summary A case of sudden unexpected death of a 13-month-old child is reported. The immediate cause of death was aspiration of stomach contents. The autopsy and microscopical examinations revealed cerebral oedema, organ congestion and an increased number of neutrophils in germinal centres of mesenterial lymph nodes and spleen. The finding of ethanol and methanol (5.2 and 0.1) and of significant amounts of a surface-active agent (linear alkyl benzene sulphonate) in the stomach contents indicated consumption of a fluid dish detergent prior to death. The blood ethanol concentration was below 0.1 and urine ethanol and methanol concentrations were 0.28 and 0.04. The possibility that ethanol-containing detergents may trigger hypoglycemic attacks is discussed.     

Dose reduction in subsecond multislice spiral CT examination of children by online tube current modulation

The potential of online tube current modulation in subsecond multislice spiral CT (MSCT) examinations of children to reduce the dose without a loss in image quality is investigated in a controlled patient study. The dose can be reduced for oval patient sectional view without an increase in noise if the tube current is reduced where the patient diameter and, consequently, attenuation are small. We investigated a product version of an online control for tube current in a SOMATOM Sensation 4 (Siemens, Forchheim). We evaluated image quality, noise and dose reduction for examinations with online tube current modulation in 30 MSCT of thorax/abdomen and abdomen and compared mA s for tube current modulation to the mA s in standard weight-adapted children protocols. Image quality was rated as very good, good, diagnostic and poor in a consensus by three radiologists. Noise was assessed in comparison to 24 MSCT examinations without tube current modulation measured as SD in ROIs. The dose was reduced from 26 to 43% (mean 36%), depending on the patients geometry and weight. In general, no loss of image quality was observed. Measured noise showed a decrease up to 26% and an increase up to 36%, although there was no decrease of image quality. Online tube current modulation is now used as a standard in MSCT at our institution. Dose in MSCT examinations of children can be reduced substantially in routine examinations by online tube current modulation without a loss of image quality.     

Patterns of radioiodine uptake by the lactating breast

Breast uptake of radioiodine, if not suspected, may be misinterpreted as thyroid cancer metastasis to the lung. To characterize the patterns of radioiodine breast uptake, we retrospectively studied 20 radioiodine scans that were performed within 1 week of cessation of breast feeding. Four patterns of uptake were identified: full, focal, crescent and irregular. The uptake was asymmetric in 60% (left>right in 45%, right>left in 15%), symmetric in 25% and unilateral in 15% of cases. A characteristic full bilateral uptake was present in 40% of cases. In three cases with the irregular pattern, caused in part by external contamination with radioactive milk, the uptake closely mimicked lung metastases. Delayed images, obtained in one case, showed an apparent radioiodine shift from the breast to the thyroid, suggesting that the presence of breast uptake can modulate radioiodine uptake by thyroid tissue. In a case of unilateral breast uptake, a history of mastitis was obtained, which to our knowledge has not been previously reported. Breast uptake of radioiodine may take several scintigraphic patterns that are not always characteristic of the lactating breast and may affect the apparent extent of thyroid remnant/metastasis.     

Osteolytic cortical destruction: an unusual pattern of skeletal metastases

Twenty-two histologically proven cortical metastases in 11 patients with bronchogenic carcinoma (10 squamous cell and one adenocarcinoma) were studied. The intracortical foci could be classified according to four distinctive patterns of bone destruction: small focal intracortical lesions (cookie-bite or cookie-cutter pattern); large osteolytic lesions; saucerized intracortical lesions with well-defined periosteal reaction; and lesions with predominant cortical destruction extending into the soft tissue as well as the medullary cavity. All lesions were located in the femoral bones.This material was presented in part at the closed meeting of the International Skeletal Society in Vancouver (Canada), September 1986     

Enhancement of [123I]β-CIT binding in the striatum with clomipramine: Is there a serotonin-dopamine interaction?

Many reports support the concept of serotonergic-dopaminergic interaction in the brain. However, at present, there are few methods to study this relationship in vivo. The purpose of this study was to investigate the effect of serotonin (5-HT) uptake inhibitor, clomipramine, on a dopamine (DA) transporter ligand, [¹²³I]-CIT (RTI-55), in rat brain. Dose-dependent changes in [¹²³I]-CIT specific binding induced by clomipramine were studied in the striatum (rich in DA transporter) and the hypothalamus (rich in 5-HT transporter). The changes in the time-activity curves of [¹²³I]-CIT specific binding after clomipramine injection were also examined in these two regions. Using the cerebellum as the reference region,k ₃ andk ₄ values with and without clomipramine administration were estimated by a two-compartment kinetic analysis. Clomipramine inhibited [¹²³I]-CIT specific binding in the hypothalamus, but enhanced its specific binding in the striatum in a dose-dependent manner. Kinetic analysis showed thatk ₃ in the striatum was increased by 55%. In conclusion, enhancement of [¹²³I]-CIT binding in the striatum after clomipramine administration indicated the possibility of 5-HT-DA interaction.     

Suicidalabsprung von der Kleinebelts-Brücke

Summary Some famous towers, mountains and bridges appear to be favourite places for suicidal jumping (thantopedamy). This is to a small degree the case even with the Danish Lillebaelt-bridge. One such case, which displayed peculiar circumstances, is reported, and a total of 11 cases, including three instances of survival, are mentioned in tables. Psychological contagious mechanisms are considered important in the choice of this suicidal method.

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Einzelheiten bereits mitgeteilt in Nord. Krim. Tidsskr. 1967, S. 1, vorgetragen auf der Tagung der Deutschen Gesellschaft für gerichtliche und soziale Medizin in Freiburg i. Br., Oktober 1966.     

In vitro and in vivo characterisation of nor-β-CIT: a potential radioligand for visualisation of the serotonin transporter in the brain

Radiolabelled 2-Cabomethoxy-3-(4-iodophenyl)tropane (-CIT) has been used in clinical studies for the imaging of dopamine and serotonin transporters with single-photon emission tomography (SPET). 2-Carbomethoxy-3-(4-iodophenyl)nortropane (nor--CIT) is a des-methyl analogue of -CIT, which in vitro has tenfold higher affinity (IC₅₀=0.36 nM) to the serotonin transporter than -CIT (IC₅₀=4.2 nM). Nor--CIT may thus be a useful radioligand for imaging of the serotonin transporter. In the present study iodine-125 and carbon-11 labelled nor--CIT were prepared for in vitro autoradiographic studies on post-mortem human brain cryosections and for in vivo positron emission tomography (PET) studies in Cynomolgus monkeys. Whole hemisphere autoradiography with [¹²⁵I]nor--CIT demonstrated high binding in the striatum, the thalamus and cortical regions of the human brain. Addition of a high concentration (1 M) of citalopram inhibited binding in the thalamus and the neocortex, but not in the striatum. In PET studies with [¹¹C]nor--CIT there was rapid uptake of radioactivity in the monkey brain (6% of injected dose at 15 min) and high accumulation of radioactivity in the striatum, thalamus and neocortex. Thalamus to cerebellum and cortex to cerebellum ratios were 2.5 and 1.8 at 60 min, respectively. The ratios obtained with [¹¹C]nor--CIT were 20%–40% higher than those previously obtained with [¹¹C]-CIT. Radioactivity in the thalamus and the neocortex but not in the striatum was displaceable with citalopram (5 mg/kg). In conclusion, nor--CIT binds to the serotonin transporter in the primate brain in vitro and in vivo and has potential for PET and SPET imaging of the serotonin transporter in human brain.     

Early enzyme changes in skin wounds demonstrated by isoelectric focusing in polyacrylamide gel

Summary Esterase patterns in vital skin wound extracts were observed and compared to those seen in normal skin. Employing the relatively simple method of isoelectric focusing in polyacrylamide gel, it was demonstrated that three, consecutively appearing, characteristic changes were visible in the esterase zymograms of vital (pre-mortally) injured skin as compared with skin which was uninjured or post-mortally damaged. One of these characteristics (characteristic a), since it is found only in wound reactions and not in uninjured skin, may represent an enzyme specifically produced during the wound reaction process. All three features normally appeared within 30 min of trauma and the first change within 5 min, even though it had been generally assumed that vital reactions, i.e. wound reactions, could be demonstrated only after a longer period of time. It was possible therefore to determine victim survival time and distinguish between pre- and post-mortal wounds. Also the isoelectric focusing of enzymes apparently gives a more efficient pattern band separation than previous methods.

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Zusammenfassung Durch isoelektrische Fokussierung der Extrakte aus vital verletzter Haut wurden die -Naphthylacetat-spaltenden Enzyme aufgetrennt und mit gleichartig hergestellten Extrakten unverletzter Haut desselben Menschen verglichen. Es konnten 3 nacheinander auftretende Merkmale im Esterasemuster der verletzten Haut festgestellt werden. Die mit a, b und c bezeichneten Unterschiede im Esterasemuster sind für die frühen Wundreaktionen kennzeichnend. Das Merkmal a ist eine nur in vitalen Hautwunden nachweisbare Esterase-Fraktion, die innerhalb 5 min nach der Wundsetzung auftritt. Die Merkmale b und c erscheinen nach dem Merkmal a innerhalb 30 min nach der Verletzung. Der Nachweis von a, b, c in einer Wunde erlaubt eine Beurteilung der Überlebenszeit und ermöglicht außerdem eine Unterscheidung von vitalen und postmortalen Wunden. Die isoelektrische Fokussierung von Enzymen scheint leistungsfähiger zu sein als die bisher zur Kennzeichnung von Wundenzymen angewandten histoenzymatischen und elektrophoretischen Methoden.

     

Partial volume summation: A simple approach to ventricular volume determination from CT

Summary The accurate determination of ventricular volume from computed tomography (CT) is not a trivial problem. The direct approach of measuring the area within a visually determined boundary or contour level and multiplying by the nominal slice thickness may be subject to large errors because such boundaries are not, in general, well defined. When the ventricles are filled with a high-contrast material such as metrizamide, we may use the technique of partial volume summation, a simple but accurate, clinically applicable method which may be performed on a standard DeltaScan-50 or similar system.     

Calcified convexity dura mater and acute epidural haematoma mimicking calcified chronic subdural haematoma

We report a patient with calcification of the convexity dura mater and an acute epidural haematoma. CT revealed a calcified layer between the haematoma and brain parenchyma, which mimicked acute bleeding into a calcified chronic subdural haematoma. The appearance of a calcified haematoma does not always mean a chronic lesion, and that emergency operation should not be foregone, when there is a history of acute head trauma and progressive impairment of consciousness.     

Comparison of FP-CIT SPECT with F-DOPA PET in patients with de novo and advanced Parkinson’s disease

Purpose Diagnosis of Parkinsons disease (PD) can be difficult. F-DOPA PET is able to quantify striatal dopa decarboxylase activity and storage capacity of F-dopamine, but is expensive and not generally available. FP-CIT binds to the dopamine transporter, and FP-CIT SPECT is cheaper and more widely available, but has a lower resolution. The aim of this study was to compare these two methods in the same patients with different stages of PD to assess their power in demonstrating deficits of the striatal dopaminergic system.Methods Thirteen patients with de novo PD and 17 patients with advanced PD underwent FP-CIT SPECT and static F-DOPA PET. After data transfer to standard stereotactic space, a template with regions of interest was used to sample values of the caudate, putamen and an occipital reference region. The outcome value was striato-occipital ratios. Patients were clinically examined in the off state (UPDRS-III and H&Y stage).Results Good correlations were found between striatal F-DOPA uptake and striatal FP-CIT uptake (r=0.78) and between putaminal F-DOPA uptake and putaminal FP-CIT uptake (r=0.84, both p<0.0001). Both striatal uptake of FP-CIT and that of F-DOPA correlated moderately with H&Y stage (=–0.52 for both techniques), UPDRS-III (=–0.38 for F-DOPA; =–0.45 for FP-CIT) and disease duration (=–0.59 for F-DOPA; =–0.49 for FP-CIT, all p<0.05).Conclusion FP-CIT values correlate well with F-DOPA values. Both methods correlate moderately with motor scores and are equally able to distinguish patients with advanced PD from patients with de novo PD.     

Das Problem der a-priori-Wahrscheinlichkeit bei Verwendung der Essen-Möller-Formel zur Berechnung der Vaterschaftswahrscheinlichkeit

Zusammenfassung Die Annahme der a-priori-Wahrscheinlichkeit, daß Nichtväter und wahre Väter gleichhäufig zur Begutachtung gelangen, wird an Hand von 408 Aktenfällen bestätigt.Die Berechnung der Vaterschaftswahrscheinlichkeit bietet, insbesondere bei Mehrverkehrsfällen, wertvolle Hinweise für die Vaterschaft oder Nichtvaterschaft eines Probanden, Hinweise, die durch die Angabe der Vaterschaftsausschlußchance aufgrund der Mutter-Kind-Konstellation nicht erbracht werden können. Auf Beziehungen zwischen der Vaterschaftsausschlußchance und der Vaterschaftswahrscheinlichkeit wird hingewiesen.

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The assumption of prior probability computing the plausibility of paternity by the Essen-Möller equation and its problem

Summary Among objectivists the assumption of firsthand probability, that non-fathers and true-fathers are being given an opinion on with equal frequency, yields to a rejection in calculating the probability of fatherhood according to Essen-Möller. By means of 408 cases it is shown, that this assumption does meet the actual situation. Non-fathers and true-fathers are observed equally frequent. Calculation of fatherhood probability renders a valuable reference to paternity or nonpaternity of a subject in cases of multiple intercourses. These references cannot be brought on by the statement of the exclusion chance of fatherhood based on the mother-child-constellation. The relationship between the exclusion chance and the probability of fatherhood is pointed out.

     

Vereinfachte Schädelidentifizierung nach dem Superprojektionsverfahren mit Hilfe einer Video-Anlage

Zusammenfassung Die fotografische Schädelidentifizierung durch das bekannte Superprojektionsverfahren konnte durch Verwendung einer Video-Anlage modifiziert und entscheidend verbessert werden. Das auf elektronischer Bildmischung beruhende Identifizierungsverfahren ist methodisch einfach zu handhaben und bietet dem Untersucher die Möglichkeit, in wesentlich größerem Umfang die Beziehungen zwischen Knochen- und Weichteil-proportionen und den Strukturen der Knochenoberfläche und den Einzelheiten der Weichteilform als konkret faßbare Identitätsmerkmale zu erkennen. Die große Anzahl an kontrollierbaren Merkmalen gestattet es, bei dem hohen Maß an Individualität, das der Kopf bietet, nicht nur entweder ein gutes Hineinpassen oder Nichthineinpassen eines Schädels in eine Fotografie, sondern einen Identitäts-beweis oder-ausschluß zu erreichen.

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Summary The photographic identification of a skull through the well-known superprojection technique can be modified and decisively improved by the use of a video-tape system. The identification method based on electronic photo composition is methodically simple to use. It offers the examiner the possibility to recognize the relationship between bone and soft part proportions, and the structure of the bone surface and the details of the soft part shape, as a concrete, tangible characteristic of identity to a substantially greater extent. The large number of controllable characteristics inherent in the high degree of individuality of the skull offers not just an either/or The skull fits/ It does not fit into a photograph, but achieves proof or disproof of identity.

Für die sorgfältige technische Assistenz danken wir Herrn A. Suhl