促肾上腺皮质激素依赖性库欣综合征患者岩下窦静脉采血的临床应用探讨

目的 研究并探讨岩下窦静脉采血(IPSS)在疑难库欣综合征(CS)诊断中的应用价值。方法 16例疑难CS患者行双侧岩下窦和外周静脉采血,测定岩下窦与外周静脉血促肾上腺皮质激素(ACTH)浓度比,评价IPSS对库欣病诊断的敏感度和特异度。结果 13例患者岩下窦与外周静脉血ACTH的比值＞2.0,其中12例经蝶窦垂体手术治疗,病理证实为垂体ACTH腺瘤;1例行鞍区γ-刀治疗,治疗后患者症状好转。3例岩下窦与外周静脉血ACTH的比值＜2.0,其中2例为右肺类癌,另1例为垂体ACTH腺瘤。IPSS诊断库欣病的敏感度和特异度分别为13/14和2/2。结论 IPSS诊断疑难库欣病的敏感度和特异度均较高,且操作安全,并发症少,可作为疑难CS的重要鉴别手段,值得临床上进一步推广应用。     

Extensor mechanism of the fingers: MR imaging-anatomic correlation.

Extension of the fingers is a complex function carried out by simultaneous action of extrinsic and intrinsic muscles, as well as retinacular structures in the dorsum of the wrist, hand, and fingers that support and coordinate the action of the muscles. The extensor mechanism of the fingers is divided into topographic zones, which extend from the forearm to the distal phalanx. Magnetic resonance (MR) imaging shows in detail the musculotendinous and retinacular structures of the extensor apparatus. In the different extensor zones, MR imaging findings are similar to those seen macroscopically in anatomic sections. Understanding of and familiarity with the extensor anatomy of the hand and fingers by the radiologist is crucial for better assessment of pathologic conditions with MR imaging and optimization of this modality as a diagnostic tool. Extensor tendon injuries and tenosynovitis represent clinical situations in which knowledge of this anatomy is useful for the clinical radiologist.     

Spring ligament complex: MR imaging-anatomic correlation and findings in asymptomatic subjects

PURPOSE: To use magnetic resonance (MR) imaging to assess the anatomy of the spring ligament complex (SLC) in cadaveric feet and to prospectively evaluate the MR imaging depiction of this complex in asymptomatic subjects. MATERIALS AND METHODS: Cadaveric feet were obtained and used according to institutional guidelines and with institutional approval and consent from the donors (before death) or the appropriate family members. Healthy volunteers were examined, with institutional review board approval and informed consent from each volunteer. MR imaging findings of the SLC in five cadaveric feet were analyzed and correlated with the findings in dissected foot specimens. Then, the MR imaging findings in the feet of 78 asymptomatic subjects were analyzed. For all three parts of the SLC, visibility, optimal imaging plane, and signal intensity characteristics were analyzed. The thicknesses of all SLC parts were measured. The measurements obtained in men and women were compared by using the Mann-Whitney U test, and Pearson correlation coefficients for associations between ligament thickness and subject age and sex were calculated. RESULTS: In the cadaveric feet, MR imaging enabled differentiation of all three parts of the SLC. The superomedial calcaneonavicular ligament (CNL) was visible in all; the medioplantar oblique CNL, in 60; and the inferoplantar longitudinal CNL, in 71 volunteers. The superomedial CNL had a mean thickness of 3.2 mm, was best seen on transverse oblique or coronal MR images, and had mainly intermediate signal intensity on T1-weighted images and low signal intensity on T2-weighted images. The medioplantar oblique CNL had a mean thickness of 2.8 mm, was best seen on transverse oblique MR images, and had mainly a typical striated appearance on T1- and T2-weighted images. The inferoplantar longitudinal CNL was the thickest (mean thickness, 4.0 mm), was best seen on coronal MR images, and had mainly intermediate signal intensity on T1-weighted images and variable signal intensity on T2-weighted images. Women had significantly thinner superomedial (mean thickness, 3.3 vs 3.5 mm; P = .015, Mann-Whitney U test) and inferoplantar longitudinal (mean thickness, 3.8 vs 4.2 mm; P = .02) CNLs than men. There was no significant correlation between ligament thickness and subject age. CONCLUSION: The superomedial and inferoplantar longitudinal CNLs are consistently visible portions of the SLC. The medioplantar oblique ligament is thinner, is seen less consistently, and has mainly a characteristic striated MR imaging appearance.     

Aberrant inferior petrosal sinus: unusual transvenous approach to the cavernous sinus

Two patients with vascular lesions of the cavernous sinus (CS) undergoing endovascular management are reported. During transvenous embolization an unusually low termination of the inferior petrosal sinus (IPS) was observed. In both patients, we were able to catheterize the CS using this aberrant venous route. Knowledge of this variant can be crucial for a successful transvenous approach and treatment of vascular lesions involving the cavernous sinus.     

Neurologic complications of petrosal sinus sampling.

Petrosal sinus sampling has been described as an innocuous, essentially risk-free procedure. The authors report on two patients from two different institutions who sustained brain stem injury as a result of petrosal sinus sampling and two other patients in whom brain stem injury was avoided. Major neurologic complications have occurred in only 0.2% of procedures (one of 508) performed at the National Institutes of Health and in 0.5% of a subset of these procedures (one of 184) that were performed with a specially designed petrosal sinus catheter. The cause of these complications is unclear but is presumed to be localized venous hypertension. Tip-deflector catheter-guide-wire systems, if available, are recommended for petrosal sinus sampling. Inadequate data exist to permit recommendation of any other catheter. Brain stem injury is preventable if the catheter is withdrawn at the earliest sign of even a minor, seemingly insignificant problem. Subtle symptoms and signs that may not appear to be neurologic may herald a clinical catastrophe if not heeded.     

The diagnosis of acromegaly: value of inferior petrosal sinus sampling

The early diagnosis of acromegaly may be difficult when serum levels of growth hormone are minimally elevated and imaging of the pituitary gland fails to show an adenoma. However, transsphenoidal surgery has the greatest chance of cure at this stage. We therefore investigated the value of sampling petrosal sinuses for measurement of growth hormone in this group of patients. Simultaneous bilateral sampling of the inferior petrosal sinuses to measure serum concentrations of growth hormone was performed in five patients suspected of having acromegaly but with nondiagnostic CT scans (n = 5) and MR images (n = 3) of the pituitary gland. Levels of growth hormone from the petrosal sinuses were five to 36 times greater than levels in the peripheral veins in all five patients, and three of four showed a marked response to growth hormone-releasing hormone. During transsphenoidal surgery, growth hormone-producing microadenomas were resected completely in four patients. In the fifth patient, a left-sided microadenoma had invaded the cavernous sinus and could not be resected completely. Lateralization of the adenomas within the pituitary gland on the basis of differences in levels of growth hormone between the two petrosal sinuses was not completely reliable. Elevated levels of growth hormone in selective samples from the inferior petrosal sinuses can help support an early diagnosis of acromegaly when peripheral growth hormone levels and imaging are not diagnostic.     

Superior petrosal sinus catheterization for transvenous embolization of a dural carotid cavernous sinus fistula

We report the endovascular treatment of a dural carotid cavernous fistula in a 67-year-old woman in whom superior petrosal sinus catheterization was performed to access the venous site of the fistula. To our knowledge, this retrograde venous route via the superior petrosal sinus has not been previously described.     

Cavernous sinus and inferior petrosal sinus flow signal on three-dimensional time-of-flight MR angiography.

BACKGROUND AND PURPOSE: Venous flow signal in the cavernous sinus and inferior petrosal sinus has been shown on MR angiograms in patients with carotid cavernous fistula (CCF). We, however, identified flow signal in some patients without symptoms and signs of CCF. This review was performed to determine the frequency of such normal venous flow depiction at MR angiography. METHODS: Twenty-five 3D time-of-flight (TOF) MR angiograms obtained on two different imaging units (scanners A and B) were reviewed with attention to presence of venous flow signal in the cavernous sinus or inferior petrosal sinus or both. Twenty-five additional MR angiograms were reviewed in patients who had also had cerebral arteriography to document absence of CCF where venous MR angiographic signal was detected, as well as to gain insight into venous flow patterns that might contribute to MR angiographic venous flow signal. Differences in scanning technique parameters were reviewed. RESULTS: Nine (36%) of the 25 MR angiograms obtained on scanner A but only one (4%) of the 25 obtained on scanner B showed flow signal in the cavernous or inferior petrosal sinus or both in the absence of signs of CCF. On review of 25 patients who had both MR angiography and arteriography, three patients with venous signal at MR angiography failed to exhibit CCF at arteriography. CONCLUSION: Identification of normal cavernous sinus or inferior petrosal sinus venous signal on 3D TOF MR angiograms may occur frequently, and is probably dependent on technical factors that vary among scanners. The exact factors most responsible, however, were not elucidated by this preliminary review.     

Value of petrosal sinus sampling: coexisting acromegaly,empty sella and meningioma

Simultaneous occurrence of an intracranial meningioma and a growth hormone (GH)-producing pituitary adenoma is exceedingly rare, as is coexistence of an empty sella and acromegaly. We report all these rare entities in the same patient. We evaluated the role of inferior petrosal sinus sampling for lateralisation of an adenoma in this patient.     

Adrenocorticotropic hormone-dependent Cushing's syndrome: sensitivity and specificity of inferior petrosal sinus sampling

BACKGROUND AND PURPOSE: Determining the cause of Cushing's syndrome can be difficult. Bilateral inferior petrosal sinus (IPS) sampling after ovine corticotropin-releasing hormone (oCRH) stimulation is an established technique for the differentiation of pituitary from nonpituitary sources of adrenocorticotropic hormone (ACTH) production. The purpose of this study was to review our experience to determine the sensitivity and specificity of bilateral IPS sampling. METHODS: Between January 1990 and February 1997, 92 patients underwent 94 IPS sampling procedures. Indications for these patients with Cushing's syndrome included no discrete lesion on MR images or CT scans, a discrete lesion present on images but equivocal peripheral ACTH sampling after oCRH stimulation, and persistent Cushing's syndrome after trans-sphenoidal surgery. RESULTS: IPS sampling yielded six false-negative results and one false-positive result, manifesting an overall sensitivity of 92.2% and a specificity of 90.0% for detection of a pituitary source of ACTH after oCRH stimulation. Microadenoma lateralization by IPS sampling after oCRH stimulation agreed with the surgical location in 70.0% of the patients. The technical success rate of initial (presampling) bilateral IPS catheterization was 93.6%. Two serious complications occurred and consisted of a venous subarachnoid hemorrhage and a lower extremity deep venous thrombosis. CONCLUSION: Bilateral IPS sampling after oCRH stimulation is helpful in the evaluation of ACTH-dependent Cushing's syndrome. False-negative results, however, suggest that the possibility of a pituitary source must still be considered when no response to oCRH is documented. Interpetrosal ACTH gradient alone is not sufficient to lateralize the tumor reliably.     

Dural arteriovenous fistulas involving the inferior petrosal sinus: angiographic findings in six patients

We report the angiographic findings from six patients with intracranial dural arteriovenous fistulas of the inferior petrosal sinus and describe the clinical presentation, vascular anatomy, and embolization techniques used in the treatment of this disorder. Dural arteriovenous fistulas at this site are rare; of 105 patients diagnosed with this abnormality, only six had lesions involving the inferior petrosal sinus. The patients included three men and three women, ranging in age from 41 to 75 years. Patients presented with bruit, proptosis, abducens palsy, or loss of vision, and symptoms were present for up to 1 year prior to diagnosis. These presentations were similar to cavernous sinus arteriovenous fistulas. The arterial supply in all cases was from branches of the external carotid artery and in three cases from the meningohypophyseal trunk of the internal carotid artery. Venous drainage in four patients was via the cavernous sinus to the superior ophthalmic vein. The remaining two patients had drainage primarily to the jugular bulb. In four patients treatment was performed by introducing wire coils into the fistula from the transvenous route. This approach could be used even though the inferior petrosal sinus was thrombosed. One patient, treated early in the series, had only transarterial embolization with both liquid adhesives and particulate embolic agents. One patient had an asymptomatic fistula that was not treated. All patients were cured, as evidenced both angiographically and clinically during the follow-up period. Three patients experienced complications from angiography and treatment: two had transverse sinus thrombosis and one had a transient ischemic attack.     

Dural arteriovenous fistula of the inferior petrosal sinus producing contralateral exophthalmus

A unique dural arteriovenous fistula of the right inferior petrosal sinus is described in which the clinical presentation that of a left caroticocavernous fistula.     

Venous subarachnoid hemorrhage after inferior petrosal sinus sampling for adrenocorticotropic hormone

Neurologic complications associated with inferior petrosal sinus sampling for adrenocorticotropic hormone in the diagnosis of Cushing syndrome are rare. Previously reported complications include brain stem infarction and pontine hemorrhage. We report a case of venous subarachnoid hemorrhage with subsequent acute obstructive hydrocephalus occurring during inferior petrosal sinus sampling for Cushing syndrome.     

MR imaging assessment of the pectoralis major myotendinous unit: an MR imaging-anatomic correlative study with surgical correlation

OBJECTIVE: MR imaging is the optimal imaging technique to study the normal and abnormal conditions of the pectoralis major muscle and tendon unit. The purpose of this study was to use MR imaging to provide an anatomic survey of the normal pectoralis major tendon and its insertion and to compare these findings with surgically proven cases of rupture. CONCLUSION: MR imaging shows the normal pectoralis major myotendinous unit has low signal intensity on both T1- and T2-weighted images. Reliable anatomic landmarks for visualization and examination of injuries to the muscle and myotendinous unit include the quadrilateral space, or the origin of the lateral head of the triceps, as the superior boundary and the deltoid tuberosity as the inferior boundary of the intact tendon of insertion. Failure to visualize a normal insertion within these boundaries should prompt a dedicated search by the radiologist for rupture and retraction of the tendon medially.     

Onyx结合弹簧圈岩下窦入路栓塞海绵窦区硬脑膜动静脉瘘

目的：探讨应用Onyx结合弹簧圈岩下窦入路栓塞海绵窦区硬脑膜动静脉瘘（csDAVF）的优势及疗效。方法：对6例csDAVF患者应用Onyx结合弹簧圈岩下窦入路栓塞,并评价疗效。结果：6例采用＂股静脉-岩下窦＂入路成功栓塞csDAVF,4例csDAVF瘘口完全闭塞,出院时症状消失;2例csDAVF次全闭塞,出院时症状改善,随访1-2个月临床症状消失。全部病例随访1-12个月,未见症状复发。结论：经＂股静脉-岩下窦＂途径,较易到达病变部位;海绵窦为闭塞csDAVF瘘口的理想部位,Onyx能在海绵窦中形成良好弥散,结合弹簧圈的应用有利于瘘口的闭塞。     

双侧岩下窦采样诊断ACTH依赖性库欣综合征的应用研究

目的 探讨双侧岩下窦采样(BIPSS)对ACTH依赖性库欣综合征(CS)的诊断价值.方法 43例CS患者行BIPSS和垂体MRI检查,用ROC曲线分析它们的诊断价值.结果 BIPSS定性诊断CS的灵敏度为0.95、特异度为1.00、阳性预测值为1.00、阴性预测值为0.71,ROC曲线下面积(AUC)大于垂体MRI;对库欣病(CD)垂体瘤的定位诊断准确率为84.21%,亦高于垂体MRI.结论 BIPSS是诊断ACTH依赖性CS的较好方法.