Proton magnetic resonance spectroscopy-guided biopsy for cerebral glial tumors.

BACKGROUND AND PURPOSE: Although application of proton magnetic resonance (MR) spectroscopy in the diagnosis of brain tumors has been reported, the role of this technique as guidance for targeting biopsy of brain tumors is not well established. The usefulness and limitations of predicting tumor proliferative activity and pathological grading of brain gliomas based on samples obtained from proton MR spectroscopy-guided stereotactic biopsy also remains unclear. The purpose of this study was to evaluate the usefulness of single-voxel MR spectroscopy-guided stereotactic biopsy for cerebral gliomas and to correlate the findings of MR spectroscopy with proliferative activity (measured by Ki-67 labeling index) of tumors and pathological diagnosis. METHODS: Localized proton spectra were obtained before stereotactic/surgical biopsy in 7 patients with glioma (8 lesions). Metabolic values in the spectra were measured semiquantitatively and correlated with the Ki-67 labeling index and pathological grade of each surgical specimen. RESULTS: MR spectroscopy-guided biopsy was effective in obtaining a representative specimen for accurate pathological diagnosis in all patients, including 1 patient with multifocal glioma and 2 with diffusely infiltrated gliomas (gliomatosis cerebri). Those lesions with higher choline complex/creatine ratio (Cho/Cr) and lower N-acetyl-L-aspartate/creatine values in MR spectroscopy were higher grade tumors. Higher Ki-67 labeling index (indicating higher proliferative activity of tumor) with higher Cho/Cr ratios in MR spectroscopy were significantly correlated with tumor grade. CONCLUSIONS: MR spectroscopy-guided biopsy was effective in obtaining a representative specimen for accurate pathological diagnosis, and the Cho/Cr ratio of MR spectra and Ki-67 labeling index were reliable predictors of glioma grade.     

Persecutory delusions in dementia.

BACKGROUND: Persecutory delusions are common in dementia. This study was undertaken to investigate the prevalence, associated factors, and characteristics of persecutory delusions in demented patients. METHOD: The sample population included 167 demented patients (DSM-III-R criteria) admitted to a geropsychiatric ward. Patients were assessed for the occurrence of any persecutory delusions since the onset of dementia. The content of persecutory delusions, the patients' response to the delusions, and any concomitant psychiatric symptoms were also explored. RESULTS: Of the 167 demented patients, 45 (26.9%) showed symptoms of persecutory delusions. Patients with persecutory delusions had a higher prevalence of other delusions, hallucinations, and physically aggressive behaviors. The deluded patients often thought that their caregivers were their persecutors and had a wide range of responses to their delusions. After they were hospitalized, many of these patients attacked medical staff and were uncooperative with treatment. CONCLUSION: Persecutory delusions are common in dementia of various types. Deluded patients often have vigorous responses to their delusions including physically aggressive behaviors and suicide attempts. Careful evaluation is needed to assess the potential for violent and suicidal behaviors in these patients. Medical staff should be alert to clinical strategies for handling the treatment of such patients when they become violent or uncooperative.     

Inappropriate sexual behaviors in dementia: a preliminary report

We investigated types of inappropriate sexual behavior (ISB) and patient characteristics in geriatric patients with dementia. The study group consisted of 133 consecutive geropsychiatric demented patients admitted to our ward. All patients underwent standardized diagnostic procedures for dementia, and ISB was assessed by a questionnaire completed by patients' caregivers and records during hospitalization. Patients were then subdivided on the basis of the presence or absence of ISB. Of the 133 demented patients, 20 (15.0%) were reported to demonstrate ISB at home or during hospitalization. Patients with ISB had various types of dementia. There were no significant differences in patients with and without ISB in regard to age, age of onset, gender, educational level, or Mini-Mental State Examination scores. ISB is not unusual in dementia patients and can be found in different types of dementia. Medical care providers need to be trained to discuss sexual issues with caregivers and offer ideas and training to help cope with patients with ISB.     

Endovascular management of the traumatic cerebral aneurysms associated with traumatic carotid cavernous fistulas

BACKGROUND AND PURPOSE: Simultaneous traumatic carotid-cavernous fistulas(TCCFs) and traumatic cerebral aneurysms (TCAs) of the internal carotid artery (ICA) are rare. We describe the pitfalls of detecting a TCA before TCCF occlusion and the endovascular management of the TCA and TCCF. METHODS: Over 12 years, 156 patients with TCCFs were treated at our institute. In four men (mean age, 34 years), associated TCAs were detected before (n = 1) or after (n = 3) endovascular occlusion of the TCCFs. Causes for the missed detection of the TCA before TCCF occlusion were masking by a parent artery and fistula drains (n = 1), steal phenomenon (n = 1), and a latent period (n = 1). The TCAs were in the supraclinoid ICA (n = 3) or the paraophthalmic artery (n = 1). Three TCAs were treated with the endosaccular placement of electrodetachable coils. RESULTS: Two TCCFs and associated TCAs were successfully occluded with preservation of the ICA. The paraophthalmic TCA was treated with coil occlusion of the TCA and TCCF. Spontaneous fatal rupture of the TCA occurred in one patient after subtotal TCCF occlusion. No notable procedure-related complication was observed in the other three patients. CONCLUSION: TCAs may be difficult to detect before treatment of the TCCF because it may be overlooked, a latent period may occur, flow may be shunted, or they may be masked by a nearby parent artery or fistula drains. As soon as a TCA is found, endovascular management should be initiated promptly.     

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.     

Use of CT angiography in patient selection for thrombolytic therapy

It has been shown that thrombolytic therapy can improve clinical outcome in some patients with acute cerebral ischemia. These patients have been reported to be characterized by certain clinical and imaging findings, mainly with non-contrast enhanced computed tomography (CT). Our purpose in this study was to find out whether CT angiography (CTA) information about the status of the cerebral vessels is helpful in the selection of patients who may benefit the most from thrombolytic therapy for acvte cerebral ischemia. CTA was prospectively performed in 15 consecutive patients (6 women and 9 men; age range 44-83 years) with moderate or severe symptoms of hyperacute cerebral ischemia. The clinical manifestations of the patient's condition and the findings on CTA were analyzed. Three-dimensionally reconstructed CTA images of diagnostic quality could be obtained for all 15 patients. Of the 15 patients 14 had a vessel occlusion identified on CTA, which was consistent with and/or helpful for making the clinical diagnosis in all 14 cases; one patient had an aneurysm of the anterior communicating artery without detectable hemorrhage on CTA. Although a thrombolytic agent was not given because of CTA evidence of intracranial aneurysm, the patient nevertheless developed a massive subarachnoid hemorrhage during hospitalization. Ischemic symptoms reversed after CTA and before the initiation of thrombolytic therapy in 2 patients whose CTAs showed occlusion of secondary branch of the middle cerebral artery (MCA). CTA can provide important information before the initiation of thrombolytic therapy. Identification both of the occluded vessel and of an intracranial aneurysm is feasible with the use of CTA, which is particularly important if the intracranial aneurysm is a potential contraindication to thrombolytic therapy. Occlusion of a secondary branch of the MCA and internal carotid artery occlusion are valuable prognostic predictors.     

MR findings of spontaneous intracranial hypotension

Purpose:
To present the MR features of spontaneous intracranial hypotension (SIH) and to discuss the correlation of MR features with clinical manifestations. Material and Methods:
Between 1997 and 2000, 15 patients with SIH underwent brain MR investigation. Lumbar puncture for the measurement of cerebrospinal fluid (CSF) pressure was performed in 6 patients. Follow-up MR was obtained in 8 patients after the clinical symptoms had improved. We analyzed the MR findings of SIH, and discuss them in relation to CSF pressure and clinical manifestations. Results:
Fourteen of the 15 patients with SIH had abnormal MR findings. The imaging findings included: diffuse pachymeningeal enhancement in 13 patients; descent of the brain in 6 patients; and subdural effusion/hematoma in 2 patients. Low CSF pressure was shown at lumbar puncture in 5 out of 6 patients. Follow-up MR examination in the symptoms-relieved status demonstrated a recovery of the abnormal MR findings in 6 of 8 patients. Conclusion:
Our data revealed that MR is sensitive in diagnosing SIH. The presence of characteristic clinical manifestations and MR features are virtually diagnostic for SIH syndrome. Invasive lumbar puncture is thus reserved for the equivocal cases.     

MRI of papillary meningiomas in children

We report two cases of papillary meningioma in children. The MRI appearance of this special type of meningioma is described for the first time. Both lesions were dura based and associated with cystic components. We review the literature pertaining to this type of meningioma and discuss the differential diagnosis of the MRI appearance. Because this is a malignant type of meningioma, early diagnosis and surgical intervention are important in the management of patients.