A review of the clinical significance of lumbar puncture in the diagnostic approach of Aneurysmal Subarachnoid Hemorrhage (SAH): A case report of CT-Negative and Lumbar Puncture–Positive SAH

@#Headaches are a common presentation in the emergency department (ED). Even though not all are potentially serious, some such as subarachnoid hemorrhage (SAH) can be more dangerous than others. SAH is a medical emergency with an almost 50% mortality rate. It is crucial not to miss the diagnosis of SAH, as a missed or delayed diagnosis can be severely detrimental. It classically presents as thunderclap headache, a severe, sudden-onset headache. There are various approaches in diagnosing or excluding SAH, which is classically done by performing a computed tomography (CT) scan followed by a lumbar puncture (LP). But with the improved sensitivity of more modern diagnostic tools, more physicians are in support of changing this classical teaching. The aim of this case report is to review the advantages and disadvantages of LP in diagnosing SAH, along with other diagnostic tools commonly used.

Study on Role of Computed Tomography in Diagnostic Workup of Headache at a Tertiary Care Hospital

To determine the etiology of headache in patients undergoing computed tomography (CT) scan of brain without having prior neurologic abnormality and to know the age incidence and the sex incidence of the headache. Methods: A prospective study of one year duration was carried out at tertiary care hospital from Aug 2018 to Aug 2019. It included 1250 patients who underwent brain CT for headache. CT findings of patients were recorded and analyzed. Results: These etiologies were sinusitis (8.8%), followed by tumor (6.8%), infarct (6.4%), hematoma (4.4%), encephalitis (3.8%), abscesses (3.2%) and hydrocephalus (1.2%). Headache is more common in females (55%). Most common age group affected is 40-60 years (37.2%). Conclusions: CT of brain has revealed in 65.1% of cases as normal and detected the various causes in rest of the cases.

Role of Computed Tomography in detecting the cause of Headache in Patients Admitted to a Tertiary Care Hospital in South Odisha

To determine the etiology of headache in patients undergoing computed tomography (CT) scan of brain both with or without neurologic abnormality in South Odisha. Methods: A prospective study of six months duration was carried out at the M. K. C. G Medical College & hospital. It included 200 patients who underwent a brain CT for headache. CT findings of patients were analyzed. Results: The total number of our patients was 200. These etiologies were stroke (15%), followed by tumor(11%),sinusitis(7.5%),trauma (7.5%), abscesses(5%) and encephalitis (4%). Conclusions: CT of brain has revealed in 62.5% of cases as normal and detected the various causes in rest of cases.

Optimizing the scan protocol in whole-brain perfusion imaging with 320-MDCT / 中华放射医学与防护杂志

Objective To evaluate the feasibility of optimized scan protocol in whole-brain perfusion imaging with 320-MDCT scanner.Methods Twenty healthy volunteers were randomly divided into control group (13 patients) and test group (7 patients).The standard perfusion scan protocol (collecting 19 volumes)was applied in control group.The optimized perfusion CT scan protocol(collecting ll volumes)formulated by reducing scanning phases reasonably and changing the collection intervals was applied in test group.The regions of interest(ROI) with area of(20 ± 2)mm2 were located in the bilateral frontal white matter,parietal white matter,centrum semiovate,basal ganglia,occipital lobe and cerebellum.Bilateral perfusion values from ROI were measured,including cerebral blood volume(CBV),mean transit time (TTP),cerebral blood flow (CBF),mean transit time (MTT) and delay time (DT).Results Dose length product (DLP)and effective dose (ED)in optimized protocol were decreased 42.02％ as compared to control group.Every relative perfusion value of both sides from both groups were not statistically significant (P ＞ 0.05).Every relative perfusion parameters from individual territory in both groups showed no significant differences (P ＞ 0.05).Conclusions Using the optimized scan protocol,we could obtain the same whole-brain perfusion values could be obtained with the default standard protocol and less radiation dose.

Application of Brain Computerized Tomography to High Voltage Electrical Burns

PURPOSE: High voltage electrical injuries can cause many complications of central nervous system. We tried to define the indication range of brain CT (computerized tomography) in high voltage electrical injuries. METHODS: We performed a retrospective analysis of 51 high voltage electrical injured patients who were confirmed by brain CT, they had visited our emergency department from January 2005 to December 2007. All patients were classified by brain CT findings, presences of combined injuries and neurologic symptoms. RESULTS: 48 patients were confirmed normal in brain CT findings. 3 patients had brain lesions that were associated with secondary trauma. There was no abnormal CT finding in the 23 patients who did not have loss of consciousness, falling and combined injuries. CONCLUSION: If patient with electrical injury did not have neurologic symptoms or sufficient mechanical force, brain CT is not recommended. The results of this study may help emergency physicians to avoid unnecessary brain CT examination in the emergency triage to a high voltage electrical injury patients.

Primary Meningeal Pheochromocytoma: A Case Report

Pheochromocytoma is a rare endocrine tumor arising from the chromaffin tissue, and it is able to produce and secrete catecholamines. Lymph nodes, liver, lung and bone are the most frequent sites of metastasis. We report here on a case of pheochromocytoma arising from the dura in a patient who was surgically treated for bilateral pheochromocytoma five years previously.

Contrast Extravasation into an Acute Spontaneous Intracerebral Hematoma: Multidetector CT Angiographic Findings and Clinical Implications

PURPOSE: The purpose of this study was to evaluate multidetector row CT (MDCT) angiographic findings and their clinical significance for contrast extravasation into a spontaneous intracerebral hematoma (ICH). MATERIALS AND METHODS: MDCT angiographic studies and clinical records of 115 patients with spontaneous ICH were retrospectively reviewed. Cases were divided into two groups according to the presence or absence of contrast extravasation. The cases in the two groups were compared to determine the differences in radiological and clinical findings. The contrast extravasation group was divided into two subgroups according to radiological findings as follows: single or multiple dot-like contrast extravasation (Type A) and beaded-tubular (with or without dot-like extravasation) contrast extravasation (Type B). RESULTS: Contrast extravasation was seen in 38 patients (33%). It was associated with a larger hematoma volume, more frequent intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH), a shorter time interval from onset to the time of the CT scan, lower Glasgow coma scale (GCS), and a higher mortality rate. Type A and B contrast extravasation were observed in 16 (42%) and 22 (58%) patients, respectively. The rate of IVH and the clinical outcome of patients with Type B showed a significant correlation. CONCLUSION: Two types of contrast extravasation into an ICH show a significant difference in the rate of IVH and in clinical outcome. Detecting the presence of contrast extravasation and classifying them according to the morphologic patterns are important in predicting a prognosis.

CT and MR Imaging Findings of Subdural Dermoid Cyst Extending into the Right Foramen Ovale: A Case Report

Intracranial dermoid cyst is a rare congenital benign disease, representing less than 0.5% of primary brain tumors. Nevertheless, if ruptured spontaneously or during surgery, it has a poor prognosis due to chemical meningitis. Therefore, it is essential to perform accurate diagnosis and proper treatment. We report an intracranial subdural dermoid cyst that may be misdiagnosed as extracranial or epidural lesion because of extension into the right foramen ovale, and describe the CT and MR imaging findings.

The Fate of High-Density Lesions on the Non-contrast CT Obtained Immediately After Intra-arterial Thrombolysis in Ischemic Stroke Patients

OBJECTIVE: Hyperdense lesions can frequently be observed on the CT obtained immediately after intra-arterial (IA) thrombolysis, and it is sometimes difficult to differentiate contrast extravasation from the hemorrhagic lesions. The purposes of this study are to classify the hyperdense lesions according to their morphologic features and to track the outcome of those lesions. MATERIALS AND METHODS: Among the 94 patients who suffered with anterior circulation ischemic stroke and who were treated with IA thrombolysis, 31 patients revealed hyperdense lesions on the CT obtained immediately after the procedure. The lesions were categorized into four types according to their volume, shape, location and density: cortical high density (HD), soft HD, metallic HD and diffuse HD. The follow-up images were obtained 3-5 days later in order to visualize the morphologic changes and hemorrhagic transformation of the lesions. RESULTS: Among the 31 patients with HD lesions, 18 (58%) showed hemorrhagic transformation of their lesion, and six of them were significant. All the cortical HD lesions (n = 4) revealed spontaneous resolution. Seven of the soft HD lesions (n = 13) showed spontaneous resolution, while the rest of the group showed hemorrhagic transformation. Among them the hemorrhage was significant in only two patients (2/6) who did not achieve successful recanalization. All the metallic HD lesions (n = 10) resulted in hemorrhagic transformation; among them, three cases (30%) with a maximum CT value more than 150 HU (Hounsfield unit) subsequently showed significant hemorrhagic transformation on the follow-up CT. There were four diffuse HD lesions, and two of them showed hemorrhagic transformation. CONCLUSION: The parenchymal hyperdense lesions observed on the CT obtained immediately after IA thrombolysis in ischemic stroke patients exhibited varying features and they were not always hemorrhagic. Most of the soft HD lesions were benign, and although all of the metallic HD lesions were hemorrhagic, some of them were ultimately found to be benign.

Development of PC-based Software to Analyze Dynamic Cerebral Perfusion CT Quantitatively and to Reformat Perfusion Maps

PURPOSE: The purpose of this study was to develop PC-based perfusion software using Microsoft Windows. This software was developed to reformat perfusion maps including CBV (Cerebral Blood Volume), MTT (Mean Transit Time), and CBF (Cerebral Blood Flow) maps and to analyze perfusion quantitatively. MATERIALS AND METHODS: Windows-based perfusion software was developed using IDL (Interactive Data Language) as the development tool. The perfusion software was written to load the source image from dynamic first-pass cerebral perfusion CT and to reformat perfusion maps. Mean perfusion values in gray matter and white matter were calculated and compared to previously calculated data reported in literature. RESULTS: This software reformatted first pass perfusion maps in a user-friendly PC and calculated CBV, MTT, and CBF values. The values were within the normal range of the mean values when compared to previous studies. CONCLUSION: CT perfusion maps and perfusion values can be obtained by using the newly developed PC-based perfusion software. Further study is needed to achieve more precise values. However, we believe that in the future, this program may be used in various clinical settings.

The use of brain CT Scan in craniocerebral trauma with Glasgow coma scale scores of 13 – 15 in Dr. Cipto Mangunkusumo Hospital 1999-2001.

There is still a controversy among the neurologists whether brain CT scan must be performed on the mild head trauma patients. This study was executed to find out the correlation between the brain CT scan image findings and its clinical impairment among the mild head trauma patients with Glasgow coma scale (GCS) score of 13 to 15. The study was a retrospective study by analyzing the uniform medical records of the head trauma patients hospitalized at the Neurology ward of Dr. Cipto Mangunkusumo Hospital within the period of 1999 to 2001. During that period 1,663 patients were hospitalized due to head trauma, and 1,166 of them (70.1 %) were suffered from mild head trauma patients with GCS score of 13-15. Among those with brain CT scan examinations (N: 271), the neurological abnormalities were found on 144 (53.1%) of patients, consisted of cerebral edema (11,4%), intracerebral hemorrhage (5.5%), epidural hemorrhage (16.2%), subdural hemorrhage (18.1%), subarachnoid hemorrhage (5.5%), and combination (13.8%). The further analysis showed that cranial nerves disturbance, amnesia, loss of conciousness for more than 10 minutes, and vomiting are significantly correlated to the brain CT scan abnormality. Combination of the above four clinical signs and symptoms have sensitivity of 90 % in predicting brain insults. This findings may be used as a simple set of clinical criteria for identifying mild head trauma patients who need undergo CT scan examination.

Usefulness of CT Perfusion Imaging in Adult Moyamoya Disease

PURPOSE: The purpose of this study was to evaluate the role of perfusion CT in adult moyamoya disease. MATERIALS AND METHODS: The study population consisted of 13 adult moyamoya patients (10 women and 3 men, mean age: 40.4 years) and 11 age-matched normal controls (5 men and 6 women, mean age: 43 years). We retrospectively assessed the perfusion CT scan both visually and by a quantitative regional analysis, and we assessed the relationship between the perfusion CT scan findings and the angiographic findings. RESULTS: The mean relative cerebral blood volume (rCBV) values in moyamoya patients were 8.0% for the MCA area, 6.4% for the PCA area, and 7.7% for the basal ganglia. The rCBV values in the patients were higher than those in the control group with statistical significance (p<0.0001). The time to peak enhancement (TTP) values of the MCA area and the basal ganglia were delayed more than those in the controls; this was statistically significant (p<0.05). Moderate correlation was found between the rCBV in the basal ganglia area and angiographic stage of the basal moyamoya vessels. CONCLUSION:Perfusion CT demonstrates a statistically significant increase in rCBV in the MCA, PCA and basal ganglia areas and the TTP in the MCA and basal ganglia areas in patients with moyamoya disease. The visual brain perfusion patterns correlate with the extent and severity of the basal moyamoya vessels.

Cerebral Fat Embolism as a Rare Complication of Postgastrectomy: Case Report

Cerebral fat embolism syndrome is a rare complication of trauma, and it particularly involves fractures of the long bones. This syndrome may occur in a diverse series of conditions such as diabetes mellitus, acute hemorrhagic pancreatitis, acute fatty cirrhosis, prolonged corticosteroid therapy, lymphography and liposuction. The author reports the CT and MRI findings in a patient with cerebral fat embolism that occurred as a rare complication of postgastrectomy.

Middle Cranial Fossa Epidermoid Cyst: A Case Report of Unusual CT and MR Findings

Intracranial epidermoid cysts usually show homogeneous hypodensity on CT scans, hypointensity on T1-weighted MR images and hyperintensity on T2-weighted MR images. Most of them arise in the cerebellopontine angle and parasellar areas. We report a case of middle cranial fossa epidermoid tumor with unusual image findings. The entire tumor mass showed inhomogeneous low density, without any enhancing solid portion on the CT scans. The lateral portion of the tumor showed homogeneous T1 low signal intensity and T2 high signal intensity. The medial portion of the tumor showed heterogeneous T1 and T2 intermediate to high signal intensity. On the gadolinium enhanced MR images, enhancement of the thickened dura was observed behind the tumor. Surgery and pathologic examination revealed the presence of an extradural epidermoid cyst.

Relationship between characteristics of brain-imaging and cognitive disorders in vascular dementia patients / 第三军医大学学报

Objective To investigate the characteristics of brain imaging and its relationship with the cognitive disorders in vascular dementia patients. Methods The volumes of cerebral lobes and hippocampus formation in 30 ischemic vascular dementia patients and 30 normal controls were measured with MRI based technique. The indices of ventricles and cerebral sulci in 30 ischemic vascular dementia patients and 30 patients with ischemic stroke were calculated with CT based technique. The cognitive functions were assessed by psychometric testing (Mini Mental State Examination MMSE, Brief Screening Scale for Dementia BSSD, Raven's Standard Progress Matric RSPM) in all subjects. Results The volumes of frontal and temporal lobes in vascular dementia patients were smaller than those in ischemic stroke patients and normal control subjects ( P 0.05). The decrease of the volumes of the frontal and temporal lobes were positively correlated with the decrease of MMSE and BSSD scores. The cognitive disorders were more severe in the ischemic vascular dementia patients with pathological foci in the frontal and temporal lobes, multiple infarcts, and the total volume of infarcts greater than 50 mm 3 ( P

Fluid Attenuated Inversion-Recovery Magnetic Resonance Imaging of Acute Subarachnoid Hemorrhage: Comparison with Non-Contrast-Enhanced Computed Tomography

OBJECTIVE: Our aim is to evaluate the usefulness of fluid-attenuated inversion recovery(FLAIR) magnetic resonance(MR) imaging for detection of acute subarachnoid hemorrhage(SAH) compared with non-contrast-enhanced computed tomography(CT). METHODS: We compared FLAIR MR images with non-contrast-enhanced CT scans in 34 patients with acute SAH. Findings of SAH on CT and MR images were graded as 0(absence), 1(suspicious), and 2(definite) in the cerebral sulci, sylvian fissures, basal cisterns, and cisterns of the posterior cranial fossa. We also compared FLAIR MR images of 34 patients with those of 35 normal subjects, and then the sensitivity, specificity, and diagnostic accuracy of FLAIR MR image for detection of acute SAH were calculated. RESULTS: FLAIR MR image was superior to CT in detecting SAH in the cranial fossa posterior(1.41+/-0.74 vs. 0.78+/-0.80, p<0.05) and cortical sulci(1.11+/-0.80 vs. 0.70+/-0.83 p<0.05). There was no significant difference between FLAIR MR image and CT in detecting SAH in the basal cisterns and sylvian fissures. The sensitivity, specificity, and diagnostic accuracy of FLAIR MR image for detection of SAH were 100% in all. CONCLUSION: FLAIR MR image is useful in detecting acute SAH, especially in patients with SAH in the posterior cranial fossa and cerebral sulci.

Suprasellar Mixed Germ Cell Tumor: Case Report

Primary suprasellar mixed germ cell tumors are rare, and the characteristics of their imaging findings are not well known. We report the clinical and imaging findings of a case of suprasellar mixed germ cell tumor comprising a germinoma, immature teratoma, and yolk sac tumor.

Arachnoid Cyst in Cavernous Sinus: Case Report

Arachnoid cyst of the cavernous sinus is very rare. When present, its anatomic location frequently gives rise to cranial nerve palsy. We report a case of arachnoid cyst of the cavernous sinus in a 38-year-old man with impaired eyeball movement and diplopia.

Gangliocytoma Mimicking Extra-axial Tumor: A Report of Two Cases

We report two cases of supratentorial gangliocytomas mimicking an extra-axial tumor. MR imaging indicated that the tumors were extra-axial, and meningiomas were thus initially diagnosed. Relative to gray matter, the tumors were hypointense on T1-weighted images and hyperintense on T2-weighted images. On contrast-enhanced T1-weighted images, homogeneous enhancement was observed, while CT scanning revealed calcification in one of the two cases.

The Usefulness of Emergency Brain Computerized Tomography in Children with First Seizures

PURPOSE: This study was performed to discover whether emergency brain computerized tomogra phy(CT) is useful for the diagnosis and management of patients with first seizure. METHODS: We studied retrostpectively all children(under 15-year-old) without a history of neu rologic illness who visited Hanyang University Hospital and took a brain CT because of a first seizure attack between January 1996 and June 1999. Total 96 children were enrolled in this study and divided into groups according to seizure type, EEG finding and provoked factor. RESULTS: Among ninety six children with a first seizure(male 60, female 36), 12 patients had brain abnormalities on CT; 3 with arachnoid cyst, 2 with vascular anomalies, 2 with brain atrophy, and so on. Forty seven patients had provoked seizures, and 56 had unprovoked seizures. Abnormalities on CT were more frequently seen in children with their first unprovoked seizure without the statistical significance(P=0.395) and in those children who had focal seizure and/or focal ab normalities on EEG(P=0.016). CONCLUSION: Emergency brain CT is a useful investigative tool for patients with first unprovoked seizure, particularly for the patients with focal seizure and/or focal EEG abnormalities. The decision to perform CT should be based on a detailed history and results of careful neurologic examination. (J Korean Pediatr Soc 2001;44:562-568)