[Out-of-body experience as possible seizure symptom in a patient with a right parietal lesion]. / "Out-of-body experience" als mögliches Anfallssymptom bei einem Patienten mit rechtsparietaler Läsion.

Out-of-body experiences are reported in a variety of diseases and physiologic conditions. We report a 44-year-old patient with epigastric auras, psychomotor and grand mal seizures, and paroxysmal experiences during which he believed to have left his body and seen himself from the outside. Electroencephalography showed a right temporal and right parietal seizure pattern on several occasions, and a lesion in the right parietal lobe was detected by cranial magnetic resonance imaging. Histological examination showed a pleomorphic xanthoastrocytoma. Following extirpation of the lesion, the patient has been seizure-free for 5 years.

Education in end-of-life care: bridging disciplinary and institutional boundaries.

This paper describes the development of an interdisciplinary, interinstitutional seminar in palliative care for South Dakota students in medicine, nursing, pharmacy, chaplaincy, and social work. Student outcomes from six seminars conducted during 2001-2004 are reported, and recommendations for future educational efforts are outlined.

Superficial siderosis of the central nervous system: pathogenetic heterogeneity and therapeutic approaches.

OBJECTIVE: Superficial siderosis of the central nervous system (CNS) is a rare chronic progressive disorder caused by chronic subarachnoid hemorrhage. We present four patients with superficial siderosis of the CNS to describe the characteristic symptoms, and to discuss the pathogenetic heterogeneity and possible new therapeutic approaches. RESULTS: The causes of chronic subarachnoid bleeding in superficial siderosis were different. In two patients surgical treatment of ependymoma or cerebral cavernomas were the underlying diseases. No cause was detected in one patient. For the first time, we present one patient with vasculitis of the central nervous system associated with systemic hemochromatosis in superficial siderosis. Therapeutic approaches included exstirpation of cavernomas as the source of chronic bleeding in one patient, immunosuppressive therapy and venupunctures in the patient with vasculitis and hemochromatosis, and symptomatic treatment with chelating agents and antioxidants. The patients remained clinically stable for the follow-up period of up to 2 years. CONCLUSIONS: Our cases underline the pathogenetic heterogeneity of superficial siderosis and favor the early diagnosis for prompt initiation of therapy. Besides treatment of the underlying condition, antioxidants and radical scavengers may be effective in halting the progression of the disease.

MRI in isolated sixth nerve palsies.

In previous studies the origin of the majority of isolated sixth nerve palsies was not clear or was ascribed to vascular disease. Our purpose was determine how frequently a causative lesion was demonstrated on MRI in patients with an acute unilateral sixth nerve palsy. We performed a prospective study of 43 patients using a standardised protocol. In 27 patients (63%) a lesion was identified on the initial MRI relevant to the sixth nerve palsy; 21 (49%) were found to have a tumour or tumour-like lesion; the frequency of presumed vasculopathy in this group was 15%. There were 16 patients (37%) with an initially normal MRI, of whom 10 (62%) had a history of vasculopathy, a significantly different proportion from the group of patients with a visible causative lesion. MRI after 3-6 months was normal in all patients with a normal initial MRI. We suggest that MRI should routinely be performed in patients presenting with an acute sixth nerve palsy, even those with evidence of a vasculopathy. If the symptoms regress spontaneously and there is a history of vasculopathy, follow-up MRI is not necessary.

Proximal myotonic myopathy and proximal myotonic dystrophy: two different entities? The phenotypic variability of proximal myotonic syndromes.

Multisystemic myotonic myopathies are characterised by a variable pattern of symptoms and signs and a variable degree of disease severity. Proximal myotonic dystrophy has been described as an entity distinct from proximal myotonic myopathy because of severe proximal muscle weakness and dystrophic changes on magnetic reasonace imaging and on muscle histopathology. We describe two siblings, one of them presenting with a proximal myotonic myopathy phenotype, the other with a proximal myotonic dystrophy-like phenotype. The variability of disease expression in these two siblings suggests that a proximal myotonic dystrophy-like variant may occur in proximal myotonic myopathy.

MRI-findings after uncomplicated anterior cervical discectomy.

BACKGROUND: The anterior approach for cervical discectomy with methacrylate-implant involves manipulations on vertebral bodies and ligaments. Foreign materials like methacrylate and fibrin sponge are inserted. On postoperative MRI it may be difficult to differentiate pathological from "normal" findings caused by routine manipulations. METHOD: In this study 14 patients free of symptoms after anterior discectomy with methacrylate-implant were examined clinically and a MRI was performed on the 7th day after surgery and again after a 6 month follow-up. All patients had an uneventful recovery and no signs of inflammation after surgery. FINDINGS: Independent of the underlying pathology (e.g. soft or hard disc) 73% of the patients had a signal reduction within the vertebral bodies adjacent to the operated disc on T1-weighted spin-echo images on the 7th postoperative day. Signal intensities were normal after 6 months in all patients. Remarkable metal artifacts were present in one patient only. The methacrylate-implant could be identified as a hypo-intense structure on all sequences at any time without artifacts. In 80% of the cases a hyperintensity was found on T2-weighted images between the methacrylate-implant and the dura on the 7th postoperative day. A protrusion of the posterior ligament was present at the level of the operated disc on day 7 after surgery, which had resolved completely 6 months later. This may mimic residual disc tissue or osteophytes early after surgery. INTERPRETATION: It is very important to know this "normal" postoperative appearance of the cervical spine in order to avoid misinterpretations.

[Cerebral aneurysms in the posterior circulation. Treatment results in 44 consecutive cases]. / Zerebrale Aneurysmen im hinteren Stromgebiet.Behandlungsergebnisse bei 44 konsekutiven Fällen.

PURPOSE: Evaluation of clinical and morphological results in 44 consecutive patients with 45 aneurysms of the posterior circulation. METHODS: Retrospective analysis of patient charts and angiograms of all vertebrobasilar aneurysms diagnosed in our department between 10/95 and 08/99. All aneurysms were treated. RESULTS: 36/44 pts had a hemorrhage. Hunt/Hess (HH) gradings were as follows: HH1 in 10, HH2 in 6, HH3 in 9, HH4 in 10 cases, and HH5 in 1 case. 38 pts with 39 aneurysms were treated exclusively in the endovascular way, 3 pts with 3 aneurysms were operated on. 3 patients had to be operated upon following insufficient endovascular treatment. Endovascular treatment resulted in 63% total and 27% subtotal occlusions, results being stable in 85%. For our pts as a whole, the grading according to the Glasgow Outcome Scale (GOS) was GOS1 in 4, GOS3 in 8, GOS4 in 7, and GOS5 in 25 cases. CONCLUSION: Despite a less favourable clinical status of pts pre-treatment, the results of our interdisciplinary concept compare favourably with those of other surgical or interventional groups.

Early childhood MRI findings in complex partial seizures and hippocampal sclerosis.

Magnetic resonance imaging (MRI) was performed on an infant with typical complex partial seizures. Visual analysis revealed MRI signs of left hippocampal sclerosis (HS) at an age of 9 months. Morphometric data including volumetry and relaxometry confirming the diagnosis are shown. This is the first report of an infant younger than 2 years with typical MRI findings including morphometric data on HS.

Does additional discectomy and the degree of dural sac compression influence the outcome of decompressive surgery for lumbar spinal stenosis?

The discussion regarding factors that reliably predict the long-term surgical results in patients with lumbar spinal stenosis is still going on. This retrospective study analyses the relation between the dimensions of the dural sac and patients' clinical status before and after decompressive operations performed with or without additional discectomy. The type of surgery performed in 134 patients and the dural sac dimensions measured on postmyelograpic computed tomography in 100 of these patients were related to the Prolo scores before surgery and at follow-up (mean 46 months). The degree of dural sac compression correlated significantly with the patients' postoperative Prolo score and with the difference between the pre- and postoperative scores. The dural sac diameters predicted outcome after surgery more reliably than the preoperative Prolo scores. There was no statistically significant difference in the outcome when comparing patients with and without additional discectomy. The results presented suggest that the relief of symptoms after decompressive surgery for lumbar spinal stenosis correlates with the degree of the dural sac compression and that the simultaneous presence of disc herniation necessitating additional discectomy does not influence the postoperative outcome. However, these results have to be confirmed by prospective studies.

[Extravasation of contrast medium in local intra-arterial fibrinolysis of the carotid territory]. / Der Kontrastmittelaustritt unter der lokalen intraarteriellen Fibrinolyse im Karotisstromgebiet.

The safety of fibrinolytic therapy is determined with the incidence of intraparenchymatous hemorrhage. When interpreting CT studies after local intra-arterial fibrinolysis (LIF) in the carotid territory, one must consider that a hyperdense lesion may also be caused by extravasation of contrast material during angiography. In this study we retrospectively analyzed CT scans of 24 patients performed within 24 h after LIF and correlated the results with clinical and angiographic findings before and after therapy. Three of 24 patients (12.5%) showed striatocapsular parenchymal hematomas, 2 patients died and 1 showed marked clinical deterioration. Fifteen of 24 patients (62.5%) showed hyperdense lesions without space-occupying effect within striatocapsular infarctions. In 6 of these patients (25%) these lesions were attributable to an extravasation of contrast medium during angiography. This extravasation required at least partial recanalization of the middle cerebral artery and always occurred within a striatocapsular infarction. The pathogenesis of extravasation of contrast medium during local intra-arterial fibrinolysis is unknown. The identification of these lesions, however, is essential for the assessment of safety of local intra-arterial fibrinolysis.

Heat-related illness. Plan ahead to protect your patients.

Environmental heat illnesses range from irksome to devastating. People at particular risk are the elderly, the chronically mentally ill, the community-dwelling developmentally delayed, people without social contacts, athletes, and those without access to air-conditioning. Because heat-related deaths are preventable, community-wide response to heat emergencies, together with individual and community education programs, could greatly decrease morbidity and mortality.

MRI in sporadic Creutzfeldt-Jakob disease: correlation with clinical and neuropathological data.

To ascertain whether increased grey matter signal intensity on T2-weighted images in patients with sporadic Creutzfeldt-Jakob disease (CJD) corresponds to the stage and severity of this disease, we correlated MRI findings in four of our own and previously reported patients with sporadic CJD with the clinical variants, neuropathological changes at autopsy, duration of the disease and survival time after MRI examination. Of 15 patients with the extrapyramidal type of CJD, 10 showed increased signal in the basal ganglia on T2-weighted images. One of seven patients with the Heidenhain variant had increased signal in the occipital cortex. Patients without increased grey matter signal intensity had a longer overall duration of CJD (P = 0.035). Although the interval between onset of neurological symptoms and MRI was not different, patients without increased grey matter signal also survived longer after MRI examination (P = 0.022).

Sarcoidosis presenting as an intra- or extra-axial cranial mass: report of two cases.

Sarcoidosis may also present as an extra- or intra-axial mass involving the central nervous system. These lesions are sometimes operated upon, because a neoplasm is suspected. We report two cases of unusual tumour-like extra- and intra-axial sarcoidosis. The extra-axial mass was just medial to the jugular foramen. Its morphology and signal characteristics differed from the more common lesions in this area. The intra-axial mass was in the temporal lobe, with only minor leptomeningeal involvement. Extra-axial sarcoidosis can be confused with a meningioma because these lesions can give relatively low signal on T2-weighted images. Intra-axial masses are presumed to represent a propagation and fusion of multiple leptomeningeal granulomas through the Virchow-Robin spaces in the brain; this pattern can be sought on contrast-enhanced T1-weighted images.

[Detectability of new medial infarcts by CT: appearance of ischemic signs]. / Erkennbarkeit frischer Media-infarkte im CT: Zeitliches Auftreten von Ischämiezeichen.

PURPOSE: To evaluate the detectability of acute middle cerebral artery (MCA) infarctions by CT with regard to the time interval after symptom onset and to the infarction size. Analysis of the chronological appearance of signs of ischaemia. MATERIAL AND METHODS: Two examiners retrospectively and independently evaluated CT scans from 171 patients with acute MCA infarctions performed within 24 hours after onset of symptoms. RESULTS: 92, respectively 87% of the Infarctions were correctly diagnosed. The detection rate did not increase after the first hour after onset of symptoms. All MCA infarctions involving the lentiform nucleus, but only 83% of the infarctions covering < 33% of the MCA area, were recognised. The hyperdense middle cerebral artery sign (HMCA5) was present in 75% of the infarctions in the first 90 minutes and in 15% from hour 12 to 24. Hypodensity of the lentiform nucleus appeared within 150 minutes, hypodensity of the convexity cortex at the earliest 60 minutes after onset of symptoms. CONCLUSIONS: The detection rate of acute MCA infarctions corresponds with the infarction size, but does not significantly change after the first hour after symptom onset.

Cytomegalovirus encephalitis and primary cerebral lymphoma mimicking Wernicke's encephalopathy.

We report a 29-year-old HIV-positive patient admitted with dysarthria, ataxia and somnolence. Imaging findings were typical of Wernicke's encephalopathy, but autopsy revealed cytomegalovirus encephalitis and primary cerebral lymphoma.

[Craniocervical dissections: study strategies in MR imaging and MR angiography]. / Kraniozervikale Dissektionen: Untersuchungsstrategien in der MR-Tomographie und MR-Angiographie.

PURPOSE: To define the diagnostic efficacy of MR imaging, "time of flight" (TOF) and phase contrast (PC) MR angiography in craniocervical arterial dissections. MATERIAL AND METHODS: The MR examinations of 16 patients with proven arterial dissections (n = 20) were retrospectively analysed by three independent readers. The MR protocol included T1w spin echo sequences with and without fat saturation (SPIR), T2w-turbo-spin echo, 2D- and 3D-TOF- and 3D-PC-MRA. The study was undertaken to assess the diagnostic sensitivity of each technique in detecting typical pathological features. RESULTS: The overall sensitivity was best in 3D-PC-MRA; reaching 88% of all possible points. Intramural haematoma could be easily detected with T1W spin echo with fat saturation (100%). Intimal flap and lumen narrowing was best defined with 3D-TOF-MRA in 86% resp. 96% and 3D-PC-MRA in 69% resp. 97%. 3D-PC-MRA was superior to all other sequences in 5 cases of aneurysmal dissection (100%). CONCLUSIONS: An accurate evaluation of craniocervical arterial dissections should rely on a combined protocol including T1w spin echo with fat saturation and an axial 3D-MR angiography (if possible 3D-phase contrast MRA).

[Radiologic diagnosis of hypophyseal adenomas]. / Die radiologische Diagnostik von Hypophysenadenomen.

During the last few years the radiological approach to the diagnosis of pituitary adenomas has changed. In the present article we review the current status of techniques and indications for imaging of pituitary adenomas. First the clinical presentation and pertinent biochemical tests for the various types of adenomas are discussed. Then the important questions to be answered by the radiologists are formulated. With the advent of Magnetic Resonance Imaging (MRI) we have a very powerful tool to image the pituitary gland; however, conventional radiographs, computed tomography and angiography continue to play a role in the evaluation of pituitary adenomas under certain circumstances.