Current prognosis in fetal ventriculomegaly.

A review of 51 cases referred for evaluation of fetal ventriculomegaly revealed adequate follow-up data in 40 patients. Three of the fetuses were electively aborted and 37 were delivered. There were no cases of death in utero. Of the 37 infants who were delivered, 26 (70%) were treated with shunt placement for neonatal hydrocephalus. The reasons for nontreatment included: inaccurate diagnosis, resolution of hydrocephalus by the time of delivery, neonatal death, and parental wishes. Survival time in the 26 shunt-treated patients ranged from 5 days to 14 years (average 4.25 years); five of these patients died within the first 2 weeks of life. Among the 26 treated patients, satisfactory cognitive ability was found in 10 (38%). Of the seven surviving nontreated infants, satisfactory cognitive ability was demonstrated in six (86%). Children with myelomeningocele displayed cognitive development similar to that in patients without myelomeningocele. The findings suggest that, of patients with in utero diagnosis of ventriculomegaly, approximately one-half survive (4-year average follow-up interval) and 38% of the survivors treated with shunt insertion have normal cognitive development. No subgroup likely to benefit from in utero treatment of ventriculomegaly was identified. Associated central nervous system or systemic malformations were identified in 26 (70%) of the 37 who came to delivery. This community-acquired series, not collected from a high-risk obstetrical-perinatal service, may reflect the general experience of the neurosurgeon consulting in such cases.     

Magnetic resonance imaging of fetal urinoma

Extrarenal collections of urine have long been associated with obstructive uropathy and may preserve renal function by acting as a "popoff" valve. Although urinary extravasation manifested as urinary ascites carries a favorable prognosis, perinephric urinomas occurring prenatally are associated with poor renal function in most cases. We report the case of a baby girl with a urinoma diagnosed by fetal magnetic resonance imaging and discuss the significance of this radiologic finding.     

Pathophysiology of long-standing overt ventriculomegaly in adults

OBJECT: Long-standing overt ventriculomegaly in adults (LOVA) is a unique form of hydrocephalus that develops during childhood and manifests symptoms during adulthood. The aim of the present study was to analyze the specific pathophysiological characteristics of LOVA. METHODS: The specific diagnostic criteria for LOVA include severe ventriculomegaly in adults that is associated with macrocephalus measuring more than two standard deviations in head circumference and/or neuroradiological evidence of a significantly expanded or destroyed sella turcica. Twenty patients who fulfilled these criteria, 14 males and six females, were retrospectively studied. These patients' ages at diagnosis ranged from 15 to 61 years (mean 39.4 years). All had symptoms and/or signs indicating that hydrocephalus first occurred at birth or during infancy in the absence of any known underlying disease. The authors performed a pathophysiological study that included specific variations of magnetic resonance (MR) imaging, such as fluid-attenuated inversion recovery and cardiac-gated cine-mode imaging; intracranial pressure (ICP) monitoring; three-dimensional computerized tomography (CT) scanning; and other techniques. Hydrocephalus was caused by aqueductal stenosis in all patients. Severe ventriculomegaly involving the lateral and third ventricles was associated with a marked expansion or destruction of the sella turcica in 17 cases. Cardiac-gated cine-MR imaging did not reveal any significant movements of cerebrospinal fluid in the aqueduct. Three-dimensional CT ventriculography confirmed that the expanded third ventricle protruded into the sella and, sometimes, extended a diverticulum. Fourteen patients revealed symptoms and signs that indicated increased ICP with prominent pressure waves. Dementia or mental retardation was seen in 11 patients, gait disturbance in 12, and urinary incontinence in eight; all three of these symptoms were observed in seven patients. Thirteen patients experienced visual disturbance. Nine patients underwent ventriculoperitoneal shunt implantation as the initial treatment, leading to postoperative subdural hematoma in all seven cases in which a differential pressure valve was used. Nine patients, three of whom were initially treated by shunt placement, underwent a neuroendoscopic procedure, mainly for third ventriculostomy. Postoperatively, ICP returned to normal, and marked to-and-fro pulsatile movements at the site of ventriculostomy were recognized on cine-MR imaging in patients treated endoscopically. However, the ventriculomegaly was little improved. Consequently, all patients eventually demonstrated improvement in response to either a shunt equipped with a pressure-programmable valve or an endoscopic procedure; however, depression appeared in six patients, who required psychiatric consultation or medication. CONCLUSIONS: Such remarkably decreased intracranial compliance but relatively high ICP dynamics are the pathophysiological characteristics of LOVA. The therapeutic regimen should be determined based on the individual's specific pathophysiological makeup.     

Medical imaging in lung cancer

The routine imaging work-up of suspected lung cancer should include posteroanterior and lateral chest radiographs and, in most cases, a computed tomographic (CT) scan of the entire thorax and adrenal glands. In asymptomatic patients with adenocarcinoma of the lung, there is justification for doing routine contrast-enhanced CT examination of the brain. Further imaging workup will be suggested by the patient's history, physical findings, and laboratory findings. Magnetic resonance imaging of the chest in patients with lung cancer is being investigated, but current studies comparing it with CT demonstrate no definite advantage at this time, with the possible exception of the lung apex in which T1 weighted thin-section coronal views are useful.     

Medical imaging of the diabetic foot

Medical imaging of the diabetic foot entails a variety of imaging modalities. The diagnostic evaluation often includes a gamut of studies that include conventional radiography, CT, nuclear medicine scintigraphy, MRI, ultrasonography, and a newcomer, positron emission tomography combined with CT and leukocyte labeling. There is not yet "one best test" for sorting out the diagnostic dilemmas that are commonly encountered. Confirmation or exclusion of the frequent diagnosis of osteomyelitis often requires multiple studies, which are complementary to one another.     

Medical applications of diffraction enhanced imaging

We have developed a new X-ray imaging technique, diffraction enhanced imaging (DEI), which can be used to independently visualize the refraction and absorption of an object. The images are almost completely scatter-free, allowing enhanced contrast of objects that develop small angle scattering. The combination of these properties has resulted in images of mammography phantoms and tissues that have dramatically improved contrast over standard imaging techniques. This technique potentially is applicable to mammography and other fields of medical X-ray imaging and to radiology in general, as well as possible use in nondestructive testing and X-ray computed tomography. Images of various tissues and materials are presented to demonstrate the wide applicability of this technique to medical and biological imaging.     

Medical imaging in the management of abdominal trauma

There is a marked trend toward nonoperative management of abdominal trauma. This has been possible thanks to the advances in imaging and interventional techniques. Computed tomography (CT), angiography, and endoscopic retrograde cholangiopancreatography (ERCP) can guide the nonoperative management of abdominal trauma.     

三维超声容积对比成像定位胎儿脊髓圆锥水平

目的评估三维超声容积对比成像技术定位脊髓圆锥末端水平的可重复性。方法采用三维超声容积对比成像显示164胎正常胎儿和12胎确诊为脊髓圆锥低位胎儿的脊髓圆锥末端水平,并评估观察者内及观察者间一致性。结果所有胎儿的脊髓圆锥末端水平均可被定位,正常胎儿观察者内和观察者间的Kappa值分别为0.943和0.915,异常胎儿观察者内和观察者间的Kappa值分别为0.965和0.913。结论三维超声容积对比成像技术用于评估脊髓圆锥末端水平,其观察者间与观察者内的一致性好,获得图像清晰直观,操作简便,可应用于快速且准确评价胎儿脊髓圆锥末端水平。     

组织多普勒成像和心磁图在胎儿心律失常研究中的应用

胎儿心律失常在妊娠中、晚期很常见,不同类型的心律失常临床处理不同,因此对其正确分型至关重要。传统方法M型超声、PW及胎儿心电图均具有应用局限性。晚近新型诊断技术组织多普勒成像和胎儿心磁图技术迅速发展,在胎儿心律失常方面展现出良好的应用前景,本文对这两种技术对胎儿心律失常分型的研究进展做一综述。     

时间-空间相关成像技术的反转模式在胎儿心血管成像中的应用进展

随着三维及四维超声技术的迅速发展,时间-空间相关成像技术(STIC)已成为研究胎儿心脏的一种相对成熟的技术,其多种成像模式可提供更多结构及血流的相关信息,为临床诊断提供依据。STIC技术的反转模式可更清晰、准确地呈现心室腔和血管腔的立体结构。本文就其在胎儿心血管系统中的研究进展进行综述。     

Neonatal echocardiogram in duodenal obstruction is unnecessary after normal fetal cardiac imaging

Background

Duodenal obstruction (DO) is associated with congenital cardiac anomalies that may complicate the delivery of anesthesia during surgical repair. As most infants undergo fetal ultrasounds that identify cardiac anomalies, our aim was to determine the utility of obtaining preoperative neonatal echocardiograms in all DO patients.

Colloid cysts with and without ventriculomegaly: Role of intraoperative real-time ultrasound

Intraoperative real-time ultrasound was used to assist localization and surgical removal of colloid cysts in patients without ventriculomegaly. In the most commonly used surgical approach for removal of colloid cysts, dilated lateral ventricles can expedite the localization of lesions because, once entered surgically, a dilated ventricle offers more space near the foramen of Monro in which to work. Additionally, the enlargement of the foramen of Monro, seen with hydrocephalus, provides greater accessibility to the colloid cyst. In patients with symptoms related to intermittent obstruction of cerebral fluid flow but with normal-sized ventricles, the precise localization of the foramen of Monro and colloid cyst is more difficult and may result in unnecessary exploration/resection of brain. Using intraoperative ultrasound, the colloid cyst and adjacent anatomic structures can be clearly visualized regardless of ventricular size. Intraoperative ultrasonography has a unique role in the operative treatment of patients with colloid cysts and nondilated ventricles.     

Symptomatic progressive ventriculomegaly in hydrocephalics with patent shunts and antisiphon devices

The antisiphon device (ASD) was designed to prevent excessive negative intracranial pressure and overdrainage with cerebrospinal fluid shunts. It has been recommended for prevention of slit ventricles and extreme shunt dependency. It was used by the author in 40 children and young adults who had low pressure headaches or were judged to be at risk for the development of subdural hematomas because of extreme hydrocephalus, relatively fixed head size, or tall stature. Nine patients encountered problems with adverse symptoms in spite of shunt patency. Four had alarming neurological symptoms of coma or severe headaches after incorporation of ASDs in ventriculoperitoneal shunt systems. With patients in the horizontal position, shunt patency was documented but computed tomography revealed progressive ventriculomegaly when they were kept erect. Symptoms abated and ventricular size diminished after conversion to proximal medium pressure diaphragm or spring-ball valve systems without ASDs. Because long shunt systems with ASDs require adequate hydrostatic columns to initiate flow when patients are erect, it is theorized that such symptoms could have been prevented by placing ASDs farther downstream from the cerebral ventricles.     

The value of ventriculo-peritoneal shunting in patients with glioblastoma multiforme and ventriculomegaly

Summary Background. Patients with an advanced-stage glioblastoma multiforme (GBM) often show general motor, gait, and cognitive deterioration. Some have radiological evidence of ventriculomegaly, but the relevance of this to their symptoms may be unclear. Distinction between tumour patients who have dilated fluid spaces as a consequence of tissue loss from surgery or treatment, and those who have a symptomatic hydrocephalic process, one who may gain benefit from insertion of a ventriculo-peritoneal shunt, is an important clinical challenge. Methods. From a series of 530 GBM patients treated by a single surgeon (ZR), we retrospectively reviewed 16 patients with advanced-stage GBM who had presented with non-obstructive ventriculomegaly and clinical deterioration not explained by progressive disease. Each had been treated by insertion of a ventriculo- peritoneal shunt (VPS). Assessments included clinical features, Karnofsky Performance Scale, motor and cognitive findings, complications and survival. Findings. Ten patients benefited from insertion of the shunt, with moderate to significant cognitive improvement. Of seven patients who presented with motor symptoms, such as gait instability, general weakness, and slowness, four patients showed significant motor improvement in addition to major cognitive improvement. Early infectious complication occurred in five patients; a late shunt infection in one; one patient had symptoms related to overdrainage; and in another a mechanical shunt malfunction occurred. Three patients died from shunt-related complications. Conclusions. Insertion of a ventriculo-peritoneal shunt can improve cognitive and motor function in a small subset of patients with advanced-stage glioblastoma multiforme and ventriculomegaly. Infection is a major risk in this patient population. Correspondence: Zvi Ram, MD, Tel-Aviv Medical Center, Department of Neurosurgery, 6 Weizman st., Tel-Aviv 64239, Israel.     

Long term neuropsychological outcome and management of 'decompensated' longstanding overt ventriculomegaly in adults

Abstract Objective. We aimed to study a group of patients presenting with symptomatic longstanding overt ventriculomegaly in adults (LOVA) requiring treatment (endoscopic third ventriculostomy), and to study their long term neuropsychological status and functionality. Methods. Twenty patients were treated with endoscopic third ventriculostomy on presentation and were studied with neuropsychological assessments including the repeatable battery for the assessment of neuropsychological status and the hospital anxiety and depression scores. Pre- and post-operative MRI studies were used to assess the patency of the endoscopic third ventriculostomy (ETV) along with clinical outcome scores. Results. A variety of presenting symptoms were experienced including headache (90%), worsening imbalance, attacks of loss of consciousness and cognitive decline. Mean age of patients was 52 years (range, 17-78) with mean head circumference of 60.9 cm. ETV was successful in controlling symptoms in 89% of patients with three patients requiring shunts (gravitational valves). There were no subdurals after surgery. All patients did universally badly in all aspects of the neuropsychological studies without showing any undue anxiety or depression. Conclusion. LOVA patients can decompensate at any time in their adult life with acute symptoms, which are generally well controlled with ETV and with few complications. Sadly, the long-term effects of carrying 'asymptomatic' or compensated hydrocephalus since childhood are of a significant cognitive cost to these patients.     

Association of intracranial hypertension without ventriculomegaly and Chiari malformation: a dangerous combination

With the increased use of MRI, tonsillar ectopia, the hallmark of the adult Chiari malformation (ACM) is being more frequently recognized. However, in some cases, the patient's symptoms do not fit with the classical presentation for ACM, but are similar to intracranial hypertension (IH). The latter may be difficult to diagnose in absence of ventricular enlargement. We report a case of ACM and IHWV due to carcinomatous meningitis.