Cranial dural arteriovenous fistula: Predisposing factors to aggressive symptoms.

Objective: To evaluate the clinical and angiographic data of cranial dural arteriovenous fistula in Thai patients and to determine the predisposing factors to aggressive symptoms. Methods: Retrospective review of 71 patients with cranial dural arteriovenous fistula who underwent cerebral angiography at Siriraj Hospital between July 2002 – February 2006. Their clinical manifestations were classified as benign or aggressive symptoms. The relationship between aggressive symptoms and the following factors were studied: gender, location of the fistula, classification according to venous drainage pattern, presence of cerebral sinus thrombosis, and shunt multiplicity. Linear-by-linear association and chi-square test were used to determine statistical significance. Results: Sixteen (22.5%) of 71 patients with cranial dural arteriovenous fistula had aggressive presenting symptoms. Factors that significantly correlate with aggressive symptoms were location of the fistula, retrograde leptomeningeal venous drainage, presence of cerebral sinus thrombosis, and multiplicity. Factor which was not significantly correlated with aggressive symptoms was gender. Conclusion: This study evaluated clinical data and angiographic features of cranial dural arteriovenous fistula in Thai patients. Predisposing factors to aggressive symptoms were location of the fistula, retrograde leptomeningeal venous drainage, presence of cerebral sinus thrombosis, and multiplicity.

A comparison of MR myelography of brachial plexus injury with CT myelography and conventional myelography.

The purpose of study is to assess the accuracy of magnetic resonance myelography (MRM) of the cervical spine in patients with preganglionic Brachial Plexus Injury (BPI) by using CT myelography as the gold standard and comparing this with routine conventional myelography. Patients with a clinically diagnosis of Brachial plexus Injury were studied (9 males, 1 female, aged 16 - 42 years old) [mean age = 25.4 years old]). All patients had undergone clinical evaluation by an orthopedic surgeon and five patients had had additional somatosensory evoked potentials (SEP) performed. All patients were investigated by conventional myelography, computed tomography myelography (CTM) and magnetic resonance myelography (MRM). We used CT myelography as the gold standard and the accuracy of MRM and myelography were assessed in relative to this. The sensitivity in detecting a pseudomeningocele by MRM is 100% and the sensitivity in detecting nerve root abnormality is 90% at the level of the C5, C6 roots and 100% for the C7, C8, T1 roots. MR Myelography had many advantages over conventional and CT myelography which include the absence of radiation and the lack of need for intrathecal injection of contrast medium.

Value of computed tomography in T-stage assessment and therapy of nasopharyngeal carcinoma.

The accurate evaluation of tumor size, localization and spread of nasopharyngeal carcinoma help optimal treatment planning. The purpose of our retrospective study is to compare the T-stage of nasopharyngeal carcinoma between evaluated by physical examination and CT scan and to compare the response to treatment in the group also underwent CT (147 patients) and the group without CT staging (40 patients). The sex ratio, and the mean age of the patients in both groups was not significantly different. Radiological study showed Stage 1 the tumor confined in nasopharyngeal region. Stage II showed tumor spreading with lateral extension to the parapharyngeal region. Stage III and stage IV, the tumor spread in a superior direction to the paranasal sinus and the base of the skull. CT staging resulted in upgrading the T stage in 88/147 cases ( 59.9%). A Complete response was higher in the CT than the non CT Group at the T2 and T4 stage. CT imaging is better than clinical examination and conventional imaging in detecting the involvement of more than one wall, base of skull involvement, differentiating tumor from sinusitis, detecting intracranial invasion and neck node involvement. In Conclusion, a CT scan is require in nasopharyngeal carcinoma patients for accurate staging, modified radiation treatment and improved treatment results.

Tc-99m stannous colloid-labeled leucocyte scintigraphy in the evaluation of brain abscess.

99mTc stannous colloid-labeled leukocyte scintigraphy was used to investigate brain abscesses in patients with underlying arteriovenous malformation or other brain abnormalities. 99mTc stannous colloid-labeled leukocytes are radiolabeled neutrophils and monocytes. The radiolabeled colloid is phagocytosed by the white cells. Six patients with underlying arteriovenous malformation (AVM) post embolisation with clinical diagnosis of brain abscess were studied. The 3 patients with positive 99mTc stannous colloid-labeled leukocyte scans were diagnosed as a cerebral abscess in all cases. One patient who had a negative 99mTc stannous colloid-labeled leukocyte scan did not have a brain abscess. Another with a negative scan had a pathologic diagnosis of chronic inflammation and foreign body reaction. The third with a negative scan was studied after treatment with antibiotic and debridement. In Summary 99mTc stannous colloid-labeled leukocyte scintigraphy is useful in conjungtion with CT scanning in investigating patients with brain abscess who have other underlying brain abnormality or who have an early brain abcess, or in the follow up of patients who have already received treatment in order to evaluate infection is still present and it is appropriate treatment.

Nocardial brain abscesses.

Five cases of nocardial infection of central nervous system were reported. All patients were immunocompromised hosts due to corticosteroid and cytotoxic drugs therapy for underlying disease. Two cases showed disseminated infection. The imagings of brain abscess were presented.

Endovascular treatment of brain arteriovenous malformations in Siriraj Hospital.

Objective: To present our experience on endovascular embolization by using N-butyl cyanoacrylate and to demonstrate that this is an effective method in the treatment of brain arteriovenous malformations. Malerials and Methods: From 1992 to 1998, 92 patients with brain arteriovenous malformations who having had endovascular embolization as primary treatment was retrospectively reviewed. Results: 8 patients (8.7%) had completely cure by embolization alone wthout neurological complication. 17 patients (18.5%) were cured after combined treatment, 9 with surgical removal and the other 8 with radiosurgery. The neurological complications occurred in 17 patients (18.5%) with 3 deaths and vegetative stage. Conclusion: The endovascular embolization can cure the arteriovenous malformations that smaller than 3 cm, no matter what its location, and it is effective to reduce the nidus volume of the larger lisions, making them suitable for surgical resection or radiosurgery as to achieve te goal of complete eradication of the malformations.

Spinal lipoma.

One patient, 64 years old, with progressive bilateral sensory loss and motor weakness of both upper and lower extremities was reported. By physical examination, upper spinal cord lesion was suspected. The definite diagnosis, spinal lipoma, was based on the investigation MRI which demonstrated the position, contour and type of tissue of the lesion and surrounding structure also.

Outpatients’ satisfaction with social security service of Siriraj Hospital.

We interviewed 872 outpatients who came for Social Security Service of Siriraj Hospital. On average, this was the 1.88th time the patients had come for treatment. Most of them were younger than 40, 55 percent had finished elementary education. Most were workers in factories and the average wage was 4,131 baht/month. Female:male ratio was 6:4 and about half of them were married. Sixty-nine percent of the patients did not know what disease caused their illness. The average cost of traveling from home to the hospital was 129.65 baht. Traveling time was less than 30 minutes in 38.5 percent, 30 minutes to 1 hour in 28.7 percent, 1-2 hours in 25.8 percent. There was no problem in coming for treatment in 87.4 percent of cases; in the group who had a problem, the problem was the long distance from home to the hospital. The average time that the patients spent waiting in front of the registration card room was 10.3 minutes, examination room 43.5 minutes and pharmacy room 19.8 minutes, total waiting time 73.6 minutes. Before examination, 88.3 percent were satisfied that they were insured with Siriraj Hospital. After examination and pharmacy rooms, 78.7 percent were satisfied. Eighty-two percent answered that there was no aspect they wanted Siriraj Hospital to improve in. We investigated the satisfaction of these outpatients by using rating-scale questionnaire, 12 questions for registration card room, 14 questions for examination room and 8 questions for pharmacy. Using step-wise multiple regression, we found that the satisfaction score of each room was 81.1, 78.1 and 74.6 problem in coming for treatment and wages. For the examination room the were sex, work character, education level and traveling expense. Fore pharmacy they were waiting time and age.

The first magnetic resonance image of multiple sclerosis in Thailand.

The authors reported a 36 year old nurse with the symptoms of diplopia and fight hemiparesis for six days. She had been suffering from numbness on and off over the right side of the body for eight years for which was prescribed anxiolytic drugs. Examination revealed normal fundi, left lateral rectus paresis and horizontal phasic nystagmus. Mild right hemiparesis with exaggerated reflexes and fight Babinski sign were noted. Clumsiness of fight arm and fight leg were recorded as well as fight hemihypalgesia. Various investigations were performed. AII studies were within normal range, including blood chemistry profile, VDRL, ESR. LE, ANF, and anti-DNA. CT-scan showed normal result as well as lumbar puncture and transcranial Doppler ultrasonography. Evoked responses showed abnormal brainstem and somatosensory response, while the visual response was normal. Magnetic resonance image (MRI) was done and revealed multiple plaques over the left pons and periventricular region in both T1 and T2 weighted image. Prednisolone 60 mg/d was prescribed and she recovered satisfactorily. Within ten days, she was discharged home without any weakness. The numbness was diminished as ewll as her double vision. This is the first demonstration in Thailand using the expensive, noninvasive, sensitive and accurate MRI on MS. Investigating neurological patients using MRI still needs to be considered for cost-benefit.