Is Gd-DTPA required for routine cranial MR imaging?

Gadopentetate dimeglumine (gadolinium diethylenetriaminepentaacetic acid [DTPA]) was administered prospectively to 500 consecutive children and adults referred for routine cranial magnetic resonance (MR) imaging over a 4-month period. Pre- and postcontrast images were blindly and independently interpreted by two experienced neuroradiologists. Specific criteria were provided to the readers to define objectively when contrast material enhancement (or lack thereof) would be considered "radiologically helpful." Contrast-enhancing lesions were observed in 99 cases (20%). In only 15 cases (3%) did Gd-DTPA permit detection of lesions not also apparent on the precontrast studies. Contrast enhancement was considered radiologically helpful in 74 of the 99 cases. Lack of enhancement was considered helpful in 112 of the 500 cases (22%). Factors that may indicate increased usefulness of Gd-DTPA include increased patient age, definite lesion seen at computed tomography or precontrast MR imaging, prior craniotomy for tumor, and clinically documented systemic or central nervous system disease. Gd-DTPA should probably be used routinely for cranial MR imaging in most patients, except, perhaps, children and young adults with normal precontrast images.

Three-dimensional transcranial Doppler blood flow mapping in patients with cerebrovascular disorders.

We investigated 60 patients with cerebrovascular disorders using a three-dimensional transcranial Doppler blood flow mapping system. A composite display of the circle of Willis is created with computer assistance, allowing accurate vessel identification and optimal data documentation of blood flow velocity and direction in the basal cerebral arteries. The basilar artery was insonated in every patient; the middle cerebral artery and the most distal internal carotid artery were found in 95% of the patients, the anterior cerebral artery in 85%, and the posterior cerebral artery in 84%. Insonation problems occurred predominantly in elderly women. Transcranial Doppler blood flow mapping showed an abnormal result in 23 of 60 patients (38%). An intracranial stenosis with greater than 50% diameter reduction or occlusion was found in 10 of 31 patients (32%) with completed stroke, reversible ischemic neurologic deficit, or transient ischemic attack. Collateral blood flow mechanisms could be demonstrated in patients with extracranial carotid artery occlusions. Intra-arterial cerebral angiography performed in 21 patients confirmed the transcranial Doppler blood flow mapping diagnosis in 19 (90.5%). In one patient an arteriovenous malformation diagnosed by transcranial Doppler blood flow mapping was confirmed by magnetic resonance imaging.

Effect of thyroid hormones on the levels of metabolic intermediates in diabetic rat liver.

Experimental diabetes results in an inhibition of the glycolytic and lipogenic pathways in rat liver, while treatment of diabetic rats with T3 for four days increases the activity of a number of enzymes linked to lipogenesis. Hepatic metabolites were estimated in control (untreated), control + T3-treated, alloxan-diabetic and alloxan-diabetic + T3-treated rats. Diabetes resulted in the expected decrease in the content of fructose 2,6-bisphosphate and an increase in the content of cyclic AMP and citrate, changes consistent with an inhibition of hepatic glycolysis. Treatment of diabetic rats with T3 did not reverse these changes. There was a marked accumulation of both acetyl CoA and citrate in the diabetic rat liver, which was of even greater magnitude in diabetic and in the T3-treated group. In addition, T3 treatment significantly increased the free CoA content of liver in both normal and diabetic groups. Of the parameters measured which influence lipogenesis, including long chain acyl CoA, the energy charge and redox state of the nicotinamide nucleotides, the raised hepatic citrate content correlated most closely with the known increase in lipogenesis in diabetic rats treated with T3 for a four day period.

Head trauma due to child abuse: serial computerized tomography in diagnosis and management.

We studied both the clinical features and CT findings in 24 children who had acute head trauma as a result of child abuse. Twenty-three of them were less than 1 year of age. The diagnosis of whiplash shaken infant syndrome was made in 17. Serial CT, done in 50% of the cases, was useful in managing the medical, legal, and social aspects of the cases and in predicting the neurologic outcome. Three children died and 12 others suffered serious neurologic sequelae. The other five children has lesser degrees of deficit; one was lost to follow-up. Three were neurologically normal on follow-up visits. Two siblings of these children died of child abuse, indicating the necessity for continuing intervention in the abused child's family to prevent further abuse.

Regulation of enzymes of glucose metabolism and lipogenesis in diabetic rat liver by thyroid hormones.

Experimental diabetes in rats is associated with a degree of hypothyroidism. Hepatic enzymes involved in carbohydrate and lipid metabolism were estimated in control (untreated), control +T3 treated, alloxan diabetic and alloxan diabetic + T3-treated rats. The key glycolytic enzymes, phosphofructokinase and pyruvate kinase, were decreased in activity in diabetes and unchanged by further treatment with T3. In contrast, certain enzymes involve in lipogenesis, ATP-citrate lyase 'malic' enzyme and 6-phosphogluconate dehydrogenase, which were decreased in activity in diabetes, were increased to, or above, control values when diabetic rats were treated with T3. It is suggested that T3 deficiency may play a role in the decrease in enzyme activities observed in experimental diabetes, in particular, some enzymes associated with lipogenesis and the provision of NADPH.

Contraindications to lumbar puncture as defined by computed cranial tomography.

Papilloedema is not always an adequate predictor of potential complications from lumbar puncture, and many clinicians are using computed tomography (CT) before lumbar puncture in an effort to identify more accurately the "at risk" patient. This paper identifies the following anatomical criteria defined by CT scanning that correlate with unequal pressures between intracranial compartments and predispose a patient to herniation following decompression of the spinal compartment: lateral shift of midline structures, loss of the suprachiasmatic and basilar cisterns, obliteration of the fourth ventricle, or obliteration of the superior cerebellar and quadrigeminal plate cisterns with sparing of the ambient cisterns. These criteria should be considered to be contraindications to lumbar puncture.

Subtemporal decompression: radiological observations and current surgical experience.

Subtemporal decompression, although seldom used today for the management of hydrocephalus, pseudotumour cerebri, or premature closure of cranial sutures, is still used in many centres to alleviate intracranial hypertension caused by tumour, trauma, or severe intracranial haemorrhage. The charts of 50 patients undergoing subtemporal decompression for either severe head trauma or severe intracranial haemorrhage were reviewed. Preoperative and postoperative computed axial tomographic scans were available in 15 patients for analysis of the effects of decompression on the underlying temporal lobe. Calculation of the additional space provided by subtemporal decompression ranged from 26 to 33 cm3.

MRI of corpus callosal syndromes.

Six patients, 6 to 13 years old, with corpus callosal abnormalities diagnosed by electroencephalography or CT were studied with a 0.15 T MR imager to determine the effectiveness of MRI in evaluating midline anomalies. Spin-echo images in the coronal, axial, and sagittal planes were obtained in two patients with Aicardi's syndrome and partial agenesis of the corpus callosum, in one patient with Dandy-Walker syndrome, and in two patients with septooptic dysplasia. Inversion recovery and spin-echo images were obtained in one patient with lipoma of the corpus callosum. Partial agenesis of the corpus callosum was seen in septooptic dysplasia, an association that has not been reported previously in the radiologic literature. Direct sagittal and coronal MRI provided better anatomic visualization of the brain and ventricles than did reformatted CT. T1-weighted images are sufficient to diagnose and delineate the extent of midline cerebral abnormalities. The unique capability of direct sagittal imaging makes MRI the best procedure for evaluating corpus callosal and other midline abnormalities.

MRI of radiation injury to the brain.

Nine patients with a history of radiation of 2400-6000 rad (24-60 Gy) to the brain were examined by magnetic resonance imaging (MRI) and computed tomography (CT). MRI demonstrated abnormalities in the periventricular white matter in all patients. The abnormal periventricular signal was characterized by a long T2 and was demonstrated best on coronal spin-echo (SE) 1000/80 images. A characteristic scalloped appearance at the junction of the gray-white matter was seen on MR images of seven patients, and represented extensive white-matter damage involving the more peripheral arcuate fiber systems. This differs from transependymal absorption, which is seen best on SE 3000/80 images and has a smooth peripheral margin. Cranial CT demonstrated white-matter lucencies in six cases but generally failed to display the extent of white-matter injury demonstrated by MRI. MRI is uniquely suited to detect radiation injury to the brain because of its extreme sensitivity to white-matter edema.

MR evaluation of Chiari I malformations at 0.15 T.

Twelve patients with known or presumed Chiari I malformations and two with clinical diagnoses of multiple sclerosis were examined by magnetic resonance (MR) imaging. MR confirmed or established the diagnosis of Chiari I malformation in all 14 cases. The spin-echo technique with a short time to echo (TE = 40 msec) and a short time to recover (TR = 1000 msec) provided optimum imaging of tonsillar position, hydromyelia cavities, and cervicomedullary "kinking." Long TE (greater than 80 msec) and TR (greater than 2000 msec) increase the signal intensity of cerebrospinal fluid and may obscure the pathology. Sagittal, transaxial, and coronal images provided complementary data; sagittal and coronal views best imaged the abnormal spinal cord and tonsils, but slitlike cavities were best seen on transaxial images. Cervicomedullary kinking was found in 10 (71%) of 14 patients and in 90% of the hydromyelic patients. This high incidence suggests that in other radiologic techniques tonsillar herniation masks the kinking. Symptoms of the Chiari I malformation overlap those of demyelinating diseases and brain tumors. Our early experience suggests MR is the preferred noninvasive procedure for identifying Chiari I malformation. Moreover, the ability to portray the variable cavity morphology of hydromyelia directly offers the potential for improved shunt placement.

Spinal cord compression in breast cancer.

Myelography was performed on 78 patients with breast cancer who had signs or symptoms compatible with spinal cord compression. Of 42 patients (54%) with extradural defects, 21 (50%) had a complete block. All patients with positive myelograms (M+) had a positive bone scan and 41 of 42 (97%) had positive skeletal x-rays. Except for paraplegia, paraparesis, or a sensory level abnormality, signs and symptoms were usually not precise enough to accurately predict patients with cord lesions; however, back pain, paresthesias, and bladder or bowel dysfunction were significantly more common in M+ patients. Cerebrospinal fluid (CSF) protein was elevated in almost all M+ patients but also in approximately half of the M- group. Cytology and glucose analysis of CSF were not of value in predicting cord involvement. Response to treatment was better for patients with fewer sites of metastatic disease and a shorter time from diagnosis to treatment. There was no notable difference in survival between M+ and M- patients. Myelography remains the most precise tool for diagnosing spinal cord lesions. Unfortunately, the prognosis of patients with metastatic breast cancer is poor regardless of whether spinal cord compression is present.

Chronic seizure disorders: contribution of MR imaging when CT is normal.

One hundred consecutive patients with complex partial seizures were studied by magnetic resonance (MR) imaging and computed tomography (CT). Thirty-four patients had seizures of more than 5 years' duration, yet neurologic examinations and previous pre- and postinfusion CT scans had been normal. MR imaging demonstrated surgical lesions of potentially therapeutic significance in four of these 34 patients. Two patients underwent surgery with removal of a thrombosed arteriovenous malformation and a glioma. Although CT has been found to detect structural abnormalities, its yield of therapeutically significant abnormalities has been low.

The role of plasma lipids in carotid bifurcation atherosclerosis.

The severity of coronary artery atherosclerosis correlates with increased plasma concentrations of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides and with decreased plasma concentrations of high-density lipoprotein cholesterol (HDL-C). The role of plasma lipoproteins in the pathogenesis of cerebral atherosclerosis, however, is less clear. Several investigators report that lipoprotein abnormalities correlate inversely with the incidence of cerebral infarction. We analyzed risk factors for carotid bifurcation atherosclerosis in 121 consecutive patients who underwent cerebral angiography. This analysis revealed a significant positive correlation between the plasma TC/HDL-C ratio and the extent of carotid bifurcation atherosclerosis (p = 0.01). The extent of atherosclerosis correlated inversely with plasma concentrations of HDL-C (p = 0.02). Triglyceride concentration correlated positively with the extent of atherosclerosis with marginal significance (p = 0.07). LDL-C and TC concentrations did not correlate with bifurcation atherosclerosis (p greater than 0.1). Only 4% of the variation in the extent of bifurcation atherosclerosis was explicable on the basis of plasma lipoprotein concentrations.

Wilson's disease: evoked potentials and computed tomography.

Multi-modality evoked potentials and computed cranial tomography (CT) were performed in ten patients with Wilson's disease to determine if any of these studies would correlate reliably with neurologic status. While all four patients with CT abnormality had neurologic signs, two additional patients with neurologic findings had normal scans. Evoked responses were normal in nine patients. The remaining patient displayed abnormal visual, brainstem, and somatosensory evoked potentials, and follow-up studies after clinical deterioration revealed worsening of the brainstem and visual evoked potentials. This patient died unexpectedly from a subdural hematoma, and postmortem examination confirmed the radiographic findings of cortical atrophy of the cerebrum and cerebellum and bilateral cystic degeneration of the basal ganglia. However, localized demyelination in the visual, auditory, and sensory pathways was not present. We conclude that the clinical neurologic status of patients with Wilson's disease cannot be reliably predicted by either CT or multi-modality evoked potentials.

Results of nuclear magnetic resonance with cerebral glioma. Comparison with computed tomography.

Our experience using nuclear magnetic resonance (NMR) in eight patients with abnormalities on computed tomography (CT) scans suggesting glioma is reported. Three patients underwent biopsies. Two patients had grade II astrocytomas. Difficulty was encountered confirming the diagnosis of astrocytoma on frozen sections in one patient, and permanent sections were required for diagnosis in the other. The third patient to undergo biopsy had a grade III anaplastic mixed glioma. Biopsy of subsequent patients with probable gliomas was not done because of the risk of producing neurological deficit. The NMR images suggest that lower-grade astrocytomas are well circumscribed, whereas higher-grade gliomas affect adjacent association bundles by direct extension of tumor cells or vasogenic edema.

Two different metabolic responses to ischaemia: inherent variability or artefact?

Guinea pig hearts, perfused with (5-3H) glucose (8 mmol . litre-1) and subjected to 30 min of reduced (6%) coronary flow, exhibited two distinctly different metabolic and electrophysiological responses to ischaemia. In 22 of the 50 hearts studied (Group 1) glucose utilisation declined during ischaemia from 2.5 +/- 0.2 to 1.3 +/- 0.2 mumol . litre-1 . g-1 dry wt. In these hearts, endogenous substrates such as glucogen and triglyceride were mobilised and, although input into glycolysis may have been initially increased through accelerated glycogenolysis, estimated glycolytic flux (1.7 +/- 0.1 mumol hexose . min-1 . g-1 dry wt) remained limited. Instead, there was a large accumulation of the intermediates of glycolysis, an increase in the content of AMP and cAMP and a particularly marked decline in creatine phosphate levels. With subsequent reperfusion, these hearts all fibrillated. In contrast, in the other 28 hearts (Group 2) glucose utilisation (5.1 +/- 0.4 mumol . min-1 . g-1 dry wt) and estimated glycolytic flux (4.1 +/- 0.01 mumol hexose . min-1 . g-1 dry wt) were increased during ischaemia. In these preparations, relatively little glycogen and triglyceride were utilised, and there was less accumulation of glycolytic intermediates. Further, lower levels of AMP and cAMP were observed and creatine phosphate: creatine ratios were better maintained. These hearts did not fibrillate during reperfusion. Thus the variable susceptibility of the myocardium to ischaemic damage, as evidenced by the random incidence of ventricular fibrillation during reperfusion, may have been related to two distinctly different metabolic responses to restricted perfusion.

Differential response of liver and kidney adenine nucleotide translocase and pyruvate dehydrogenase activity to alloxan diabetes. The possible regulatory role of long chain acyl CoA.

Adenine nucleotide translocase (EC 3.6.1.3.), pyruvate dehydrogenase (active and total forms, EC 1.2.4.1) and the long chain acyl CoA content were measured in liver and kidney from normal and alloxan-diabetic rats. The long chain acyl CoA content was significantly increased in liver, but not in kidney, in the diabetic group. Adenine nucleotide translocase activity was decreased in liver and raised in the kidney of alloxan-diabetic rats relative to the control group. Pyruvate dehydrogenase (active) was inhibited to a similar degree in both tissues in diabetes. The results are discussed in the light of the possible regulatory role of long chain acyl CoA and the diverse metabolic demands of the two tissues in diabetes.

Adenine nucleotide translocase, Na+-K+-and Mg2+-ATPases and differential tissue response to hypothyroidism.

The activities of adenine nucleotide translocase (ANT), Na+-K+-ATPase (EC 3.6.1.3) and Mg2+-ATPase (EC 3.6.1.3) together with mitochondrial marker enzymes, succinic dehydrogenase (EC 1.3.99.1) and glutamate dehydrogenase (EC 1.4.1.2), were measured in liver, kidney, brain and testis from normal and thyroidectomised rats. Na+-K+-ATPase decreased by approximately 50% in liver and kidney; ANT decreased only in liver (-40%) while the activity of ANT per gram kidney increased by 38%. The activity of Mg2+-ATPase closely correlated with the pattern of change of ANT. The hormonal and substrate regulation of ANT is discussed in relation to its role in the regulation of intracellular phosphate potential and compartmentation in liver and kidney.