Cervical disk prolapse.

OBJECTIVE: To correlate the findings on computed tomographic myelography (CTM) with surgically and pathologically proven prolapsed cervical disks, mention other pertinent cross-sectional imaging studies, and note the clinical relevance of certain CTM features. DESIGN: We retrospectively reviewed the medical and radiologic records of Mayo patients with suspected degenerative cervical disk disease during a 4-year period. MATERIAL AND METHODS: Between January 1986 and December 1989, 734 patients with possible cervical disk disease underwent assessment by CTM. An extruded disk was noted in 297 of these patients. In this study group, magnetic resonance (MR) imaging was also done in 28 patients and plain computed tomography was performed in 14, and we summarized those findings. RESULTS: Of the 297 study patients, 280 had a cervical radiculopathy and 17 had a myelopathy. CTM identified more than 90% of the extruded cervical disks. CTM could not distinguish between an osteophytic cartilaginous cap and a disk, and CTM could not identify the source of a cervical radiculopathy in 102 patients. Although only a few imaging studies other than CTM were performed, those modalities were less sensitive in the detection of prolapsed disks. CONCLUSION: Imaging of cervical disk prolapse continues to be difficult, and the results are not always specific. CTM is the most sensitive imaging examination, but the number of MR studies in the current series of patients was insufficient for a reasonable comparison between the two modalities.

Primary lymphoma of the spinal cord.

Non-Hodgkin's lymphomas arising in the spinal cord are extremely rare. Only eight single case reports have been well confirmed in the literature. Herein we describe a 59-year-old woman with symptoms attributable to a spinal cord lesion. Physical examination revealed neurologic deficits but no evidence of tumor elsewhere. Although several imaging studies were performed, only magnetic resonance imaging with use of gadolinium revealed the exact site and extent of the lesion. Laminectomy and direct examination of the spinal cord disclosed a discolored region at the level of the 11th thoracic vertebra. A biopsy specimen was obtained, and pathologic examination revealed an intermediate grade, mixed cell lymphoma of T-cell origin. Radiotherapy was administered to the lesion and adjacent region of the spinal cord with use of 6-MV photons and an anteroposterior-posteroanterior technique; the total dose was 45 Gy in 23 fractions. No chemotherapy was given. After 3 years of follow-up, the neurologic signs and symptoms were stable, and repeated magnetic resonance imaging with use of gadolinium showed no residual tumor. In addition to the case report, we review the literature on primary lymphomas of the central nervous system and discuss treatment recommendations.

Cervical spondylotic stenosis and myelopathy: evaluation with computed tomographic myelography.

OBJECTIVE: To determine which components of cervical spondylosis are most frequently present in patients with myelopathy. DESIGN: We reviewed the findings in 93 patients who underwent surgical decompression for cervical spondylotic myelopathy between January 1986 and December 1989 at Mayo Clinic Rochester. MATERIAL AND METHODS: All 93 patients (72 men and 21 women) underwent computed tomographic (CT) myelography. In addition, magnetic resonance imaging scans were available in 25 patients, and plain CT scans were obtained in 2. RESULTS: A review of CT myelograms revealed that all neurocompressive intraspinal spondylotic changes were reflected in the shape of the spinal cord. Among the 93 patients with myelopathy, the configuration of the spinal cord could be categorized into primarily three dominant types: A (severe encroachment that compressed the cord into the shape of a banana; N = 40), B (moderate encroachment that produced less prominent compression; N = 23), and C (moderate bilateral uncovertebral spurs; N = 12). As a comparison group, 30 patients with similar spinal cord deformities but without progressive myelopathy were analyzed. Correlation of the two groups showed that myelopathy was present in up to 98% of patients with type A spinal cord, in 75% with type B, and in 71% with type C. The findings on magnetic resonance imaging were similar to those on CT myelography, but the bony spondylotic components were less readily seen. CONCLUSION: The precise pathophysiologic mechanism of myelopathy in spondylosis remains an enigma. Although the bulk of the data on our patients supports direct compression, we believe that the cause is multifactorial.

Surgical treatment of spontaneous intracranial hypotension associated with a spinal arachnoid diverticulum. Case report.

The authors present the case of a 22-year-old woman who developed spontaneous intracranial hypotension as a result of a cerebrospinal fluid leak from a thoracic extradural arachnoid diverticulum. The patient was successfully treated by ligation of the diverticulum. The entity of spontaneous intracranial hypotension and its relevance to neurosurgery are discussed.

Cervical neural foraminal canal stenosis: computerized tomographic myelography diagnosis.

The surgical and computerized tomographic myelography (CTM) features of 134 stenotic foraminal canals were correlated retrospectively in 95 patients. The myelographic site of stenosis was the entrance to the foraminal canal in 70 cases (52%) and the canal itself in 37 (28%); the site was not identified definitively in 27 (20%). At the entrance to the foraminal canal, encroachment on the adjacent nerve root was by a cartilaginous cap in 10 cases (8%), a bony osteophyte in 17 (13%), a synovial cyst in one (1%), and a combination of a bony and cartilaginous osteophyte in 42 (31%). The diagnostic features of stenosis within the foraminal canal were more variable. Small bone spurs arising from the uncovertebral process encroached on the anterior aspect of the foramen in 29 instances (22%), accompanied in all cases by either a congenitally narrow canal (in 16) or a diffuse osteophytically narrowed canal (in 13); osteophytes arising from the superior facet in eight instances (6%) were larger and encroached on the posterior aspect of the foramen. Diagnosis on the basis of CTM is difficult because stenosis was readily evident as a bone spur in only 13% of cases, could not be distinguished from prolapsed disc in 39%, had to be differentiated from a congenitally narrow foraminal canal in 27%, and was frankly missed in 20% of the instances of stenosis.

Movement disorders as sequelae of central pontine myelinolysis: report of three cases.

In three survivors of central pontine myelinolysis, dystonia (in two patients) and rest tremor (in one) were sequelae. The onset of these movements occurred 3 weeks to 5 months after the initial presentation with central pontine myelinolysis. Magnetic resonance imaging revealed basal ganglia lesions suggestive of extra-pontine myelinolysis in all three patients. We propose that the movement disorders seen in our cases are clinical correlates of extra-pontine myelinolysis.

Cost containment, quality assurance, and physician microscopy of cerebrospinal fluid with normal cell counts. Analysis of 1,677 consecutive specimens.

During a six-month interval, 1,677 cerebrospinal fluid (CSF) specimens with cell counts of 0 to 5 X 10(6)/L were examined by one of six physician microscopists. Malignant cells were found in ten of these CSF specimens. In seven, unidentified cells had been noted on prior review by a technologist. Technologists had a frequency of false negative errors of 0.12%. Physicians had a frequency of apparent false positive errors of 0.12%. There is little or no benefit from physician microscopic examination of all CSF specimens that have normal cell counts. Adoption of a different policy would reduce medical care costs by $40,000 for this entire series of 1,677 specimens without adversely affecting the quality of laboratory results.

Seizures activated by therapeutic levels of lithium carbonate.

We have described a 22-year-old woman who manifested clinical seizures after treatment with lithium carbonate was initiated. Serial electroencephalograms showed both nonspecific activation and activation of an epileptiform discharge with serum levels of lithium carbonate maintained within the therapeutic range.

The accuracy and limitations of intravenous digital subtraction angiography in the evaluation of atherosclerotic cerebrovascular disease: angiographic and surgical correlation.

Intravenous digital subtraction angiography (IV-DSA) and subsequent conventional selective carotid angiographic examinations were reviewed in 78 patients who were suspected of having cerebrovascular disease, and the results were correlated with surgical findings in 53 patients. The impact of the information provided by each of these examinations on subsequent therapy was reviewed. IV-DSA examinations of acceptable quality accurately depict atherosclerotic lesions in the cervical carotid arteries. We found IV-DSA to be deficient for detection of intracranial vascular disease.

Ophthalmodynamometry and ocular pneumoplethysmography for detection of carotid occlusive disease.

The accuracy of ophthalmodynamometry and ocular pneumoplethysmography for predicting pressure-significant lesions of the internal carotid system was compared in a series of 119 consecutive patients (210 arteries) having cerebral angiography. Overall accuracy (92.5%) for ocular pneumoplethysmography was significantly better than that for ophthalmodynamometry (76%). The difference was most apparent in predicting abnormality (85% for ocular pneumoplethysmography and 49% for ophthalmodynamometry), particularly for bilateral lesions (80% for ocular pneumoplethysmography and 37% for ophthalmodynamometry). There were few false-positive results with either test.

Digital angiography: introducing digital techniques to clinical cerebral angiography practice.

Digital subtraction angiography provides a computerized radiographic method of imaging the vascular system. These computer techniques may be used with arterial catheterization (digital arterial angiography) and with intravenous contrast injection (digital venous angiography). Both methods are changing the diagnostic evaluation and therapeutic follow-up of patients with cerebrovascular disease.

High-resolution dynamic ultrasound imaging of the carotid bifurcation: a prospective evaluation.

One hundren patients underwent high-resolution dynamic ultrasound imaging of the carotid bifurcation immediately before cerebral angiography. The examinations were interpreted independently. A positive ultrasound interpretation indicated the presence of moderate to extensive atheromatous plaque, while a negative interpretation indicated normal vessels or minimal atheromatous disease. Ten percent of the ultrasound examinations were technically unsatisfactory. Of the remaining studies, there was satisfactory correlation between ultrasound and angiography in approximately 85% and disagreement in 15%. The majority of ultrasound errors were "false positive" (although these probably represent false-negative angiograms). Although atheromatous disease was accurately detected by ultrasound, stenosis, ulceration, intraluminal thrombus, and vessel occlusion were not reliably identified.

Ocular pneumoplethysmography and ophthalmodynamometry in the diagnosis of central retinal artery occlusion.

Ocular pneumoplethysmography and ophthalmodynamometry measure ophthalmic arterial system pressures to assess noninvasively the hemodynamics of the carotid system. A previously unreported circumstance in which these tests complement one another is central retinal artery occlusion. Typically, the ipsilateral retinal artery pressure, measured by ophthalmodynamometry, is greatly decreased or is zero, whereas the ophthalmic systolic pressure, measured by ocular pneumoplethysmography, is normal.

Managing the epileptic patient.

A review of hospital charts revealed that only 3 (7.5%) of 40 inpatients with a diagnosis of epilepsy had received counseling about the disorder, its treatment, and its social ramifications. Although it is often neglected--as indicated by this small sample--proper and continuing patient education may dispel some of the damaging misconceptions and fears about the disorder and help the epileptic patient lead a full and productive life. Physicians should point out the importance of acceptance of the diagnosis, record keeping by the patient, awareness of precipitating factors, associated socioeconomic problems, and follow-up, stressing the possibility of normal life.

Computed tomography and radionuclide imaging in the evaluation of ischemic stroke.

One hundred forty-one patients with cerebral or cerebellar infarction were examined by computed tomography (CT) as soon after the ictus as possible. The examination was repeated in 7 days, and a radionuclide brain scan was performed. The overall detection rate for ischemic infarction was approximately equal for both techniques, ranging from 58% for radionuclide scanning to 66% for the delayed CT. Almost half of the supratentorial infarcts examined by CT on the day of the ictus were demonstrated. Mass effect was observed as early as the first day and as late as the 25th day.