Long-term treatment of invasive sinus, tracheobroncheal, pulmonary and intracerebral aspergillosis in acute lymphoblastic leukaemia.

A 59-year-old male with acute lymphoblastic leukemia developed sinus, tracheobroncheal, pulmonary, and intracerebral aspergillosis. All lesions except the intracerebral aspergillosis healed after combination antifungal treatment. Long-term voriconazole--but not posaconazole--therapy induced partial regression of the cerebral manifestations. At the time of writing, 3.5 years after the initial diagnosis, the patient is working half-time and suffers from a possible voriconazole-induced polyneuropathy.

Myelography with a dimeric (iodixanol) and a monomeric (iohexol) contrast medium: a clinical multicentre comparative study.

The purpose of this study was to evaluate and compare the radiographic efficacy and safety of iodixanol (Visipaque; 270 and 320 mg I/ml) and iohexol (Omnipaque; 300 mg I/ml) in myelography. The study was randomized, double-blind and comparative including 398 patients from five European university clinics. The radiographic visualisation was evaluated as poor, good or excellent. Adverse events were recorded by interviewing the patients after the myelography, and each patient was given a questionnaire to be returned after 1 week. In cervical myelography with cervical puncture more films with excellent quality was obtained after iodixanol 320 mgI/ml compared with iohexol 300 mgI/ml (p = 0.009). Also in lumbar myelography iodixanol 320 mgI/ml compared favourably with iohexol 300 mgI/ml (p = 0.006). The most frequent adverse event was headache, which occurred in 5-35 % of patients during the first 24 h and in 19-61 % within the first 7 days, depending on the centre. There was no difference in frequency and severity of the adverse effects between the contrast media.

Septic and aseptic post-operative discitis in the lumbar spine--evaluation by MR imaging.

PURPOSE: The aim of this study was to determine whether it was possible to differentiate septic from aseptic post-operative discitis in the lumbar spine by means of MR imaging. MATERIAL AND METHODS: The study was a retrospective evaluation of 12 patients with prior lumbar discectomy and suspected post-operative discitis displaying low-back pain and typical MR findings. Six patients had elevated serum C-reactive protein (CRP) (septic) and 6 had normal CRP (aseptic). We used MR imaging to assess the distribution and degree of changes in the disc, in adjacent bone marrow, and in surrounding soft tissue. RESULTS: Of the 6 patients with increased CRP levels, 3 had extensive MR changes typical of septic post-operative discitis: 1 found soon after surgery; 2 found later. The other 3 patients with septic discitis, who were examined in the early post-operative period, showed MR changes similar to those in the 6 patients with aseptic discitis. CONCLUSION: Suspicion of septic post-operative discitis should be confirmed by MR imaging, serum CRP, and disc puncture. MR imaging is not reliable as the sole method for distinguishing septic from aseptic discitis in the early post-operative stage.

The postoperative lumbar spine. A radiological investigation of the lumbar spine after discectomy using MR imaging and CT.

PROBLEMS AND AIMS: The clinical outcome of repeat lumbar discectomy is not as satisfactory as that of the primary surgical procedure. One reason is the difficulty of assessing post-operative radiological investigations and particularly the significance of the various radiological changes. A second problem is differentiating between the two forms of post-operative discitis, a rare but important complication after lumbar discectomy. The aims of this study were: to improve understanding of the significance of certain post-operative radiological changes; and to evaluate differences in the MR features of septic and aseptic post-operative discitis. MATERIAL AND METHODS: A total of 192 patients (209 disc levels) took part in this study; all had had prior lumbar discectomy. Nineteen of these patients were regarded as asymptomatic and they served as a control group in the evaluation of certain post-operative changes in the symptomatic patients. Twelve patients with post-operative discitis were examined in order to compare the MR features of septic and aseptic discitis. MR imaging was performed first without and then with contrast enhancement in all patients. Contrast-enhanced MR imaging was also compared with contrast-enhanced CT. RESULTS: Owing to its superiority in distinguishing the nerve roots at the surgical site, MR imaging was found to be a more valuable diagnostic method than CT. Disc herniations were found in 16% of the disc levels in asymptomatic patients and in 38% of the disc levels in the symptomatic patients. Significantly more disc herniations were found in patients who had only a short duration of recurrent symptoms (maximum 3 months) before MR investigation than in the asymptomatic patients. Nerve-root displacement due to disc herniation was also significantly more frequent in patients with the short symptom duration than in patients with a longer symptom duration. True intradural nerve-root enhancement was found in 7% of symptomatic patients, and focal enhancement in the root sleeve was found in 26% of them; there was good correlation to clinical symptoms and other pathological findings. Thickened nerve roots were found with equal frequency in asymptomatic and symptomatic patients. Epidural scar tissue diminished with time, showing no significant difference between asymptomatic and symptomatic patients. Out of 6 patients with septic post-operative discitis, 3 showed extensive MR changes; the remaining 3 showed moderate changes which were similar to those in another 6 patients who had aseptic discitis. DISCUSSION AND CONCLUSION: MR is the imaging method of choice in the evaluation of patients with recurrent clinical symptoms after disc surgery. Disc herniations may be found in asymptomatic patients; it is therefore important to assess the plausibility of the assumption that the finding of a herniated disc correlates well with the actual clinical symptoms. Nerve-root displacement and nerve-root enhancement caused by recurrent disc herniation may strengthen the indication for repeat discectomy. On the other hand, the finding of a thickened nerve root seems to be of no diagnostic value. The MR features in post-operative discitis develop only gradually and the differentiation between septic and aseptic forms of discitis is thus difficult at the early stage.

Evaluation of the post-operative lumbar spine with MR imaging. The role of contrast enhancement and thickening in nerve roots.

PURPOSE: Two new signs of lumbar nerve-root affection have been reported in recent years on the basis of MR examinations, namely: thickening in nerve roots; and contrast enhancement in nerve roots. The aim of this study was to assess contrast enhancement in nerve roots in a standardised way, and to evaluate the clinical significance of contrast enhancement and of nerve-root thickening in the symptomatic post-operative lumbar spine. MATERIAL AND METHODS: A total of 121 patients (who had previously been operated on for lumbar disc herniation) underwent 152 MR examinations, mainly on a 1.5 T system. Focal nerve-root enhancement was identified by visual assessment. Intradural enhancement was also quantified by pixel measurements that compared the affected nerve roots before and after contrast administration. Non-affected nerve roots were used as reference. RESULTS: Enhanced nerve roots in the dural sac increased at least 40-50% in signal intensity after contrast administration compared to pre-contrast images and also compared to non-affected nerve roots. Intradural nerve-root enhancement was seen in 10% of the patients and focal enhancement in the root sleeve was seen in a further 26%. Nerve-root thickening was seen in 30%. Good correlation with clinical symptoms was found in 59% of the patients with intradural enhancement, in 84% with focal enhancement, and in 86% with nerve-root thickening. The combination of thickening and enhancement in the nerve root correlated with symptoms in 86% of the patients. CONCLUSION: Nerve-root enhancement (whether focal or intradural) and thickening in the nerve root are significant MR findings in the post-operative lumbar spine. In combination with disc herniation or nerve-root displacement, these two signs may strengthen the indication for repeat surgery. However, root enhancement within 6 months of previous surgery may be a normal post-operative finding.

Tumor seeding following stereotactic biopsy of brain metastases. Report of two cases.

In a series of 22 patients treated with gamma knife surgery for brain metastasis in whom biopsy specimens were obtained via stereotactically guided procedures before the radiosurgical treatment was administered, two cases with evidence of tumor seeding were observed on subsequent follow-up examination. These findings contradict the opinion that the risk for tumor spread after a biopsy is negligible. This evidence may be explained by the fact that radiosurgery leaves the surrounding tissue unaffected by the treatment, which results in preserved anatomy around the tumor. This allows the surgeon to define the previous biopsy channel and, consequently, whether a distant tumor recurrence may have resulted from tumor seeding related to the biopsy procedure. Additionally, radiosurgical treatment leaves tumor cells that may have been spread as a result of the biopsy unaffected, giving them the potential to divide and develop into a new tumor. In contrast to this, microsurgical removal of the tumor will affect the surrounding tissue, making it impossible to detect whether new metastases are resulting from seeding. Furthermore, conventional fractionated radiation therapy will sterilize tumor cells that may have spread, thus making it impossible for these cells to regrow. The authors conclude that the risk for tumor seeding following a stereotactically guided biopsy may be higher than previously assumed.

Third ventricle colloid cysts: a consecutive 12-year series.

A continuous follow-up review of colloid cysts including aspects of natural history and evaluation of treatment options is necessary to optimize individual treatment. Thirty-seven consecutive patients with colloid cyst of the third ventricle seen at Karolinska Hospital between 1984 and 1995 were reviewed. Five patients were admitted in a comatose state, and two died despite emergency ventriculostomy. Three had recurrent cysts following previous aspiration procedure. During the study period, patients underwent a total of 10 ventriculostomies, 10 aspirations, 26 microsurgical operations, and two shunt operations. Twenty-four of 26 microsurgical operations were transcallosal and two were transcortical. Twenty-four operations (22 transcallosal and two transfrontal approaches) without permanent morbidity were performed by four surgeons. Transient memory deficit from forniceal traction was noted in 26%. The remaining two transcallosal operations, which led to permanent morbidity or mortality, were performed by two different surgeons. Aspiration of cysts performed by four different surgeons carried a 40% risk of transient memory deficit (10% permanent) and an 80% recurrence rate. One patient was found to be cured on radiological studies obtained at the 5-year follow-up review. Seven cysts were followed by means of radiological studies with no treatment for 6 to 37 months. Five of these cysts grew, indicating that younger patients with colloid cysts will probably need surgical treatment. The main causes of unfavorable results were: 1) failure to investigate symptoms that proved fatal; 2) subtotal resection; and 3) surgical complications. Transcallosal microsurgery produced excellent results when performed by experienced surgeons. A colloid cyst of the foramen of Monro is a disease that should be detected before permanent neurological damage has occurred. Permanent morbidity or mortality should not be accepted in modern series of third ventricle colloid cysts.

Postoperative lumbar MR imaging with contrast enhancement. Comparison between symptomatic and asymptomatic patients.

UNLABELLED: PURPOSE AND MATERIAL: Contrast-enhanced MR imaging of the spine after surgery for lumbar disk herniation almost always shows pathologic changes. To investigate to what extent these changes are correlated to patients' actual clinical symptoms, we compared the postoperative MR findings in 19 asymptomatic patients with 42 symptomatic patients (43 levels). METHODS: The asymptomatic patients underwent MR examination one year after surgery. Twenty-six of the symptomatic patients underwent MR one year or less after surgery, and in 16 patients (17 levels) MR was performed more than one year after surgery. RESULTS: Sixteen percent of the asymptomatic and 42% of the symptomatic patients had disk herniation at the level of previous surgery. Most of the herniated disks were found in the symptomatic patients less than one year after surgery. The amount of epidural scar tissue, displacement and thickening of nerve roots, and compression of the dural sac were also studied. Disk herniation as a probable cause of recurrent sciatica was a common finding among symptomatic patients examined one year or less after surgery. In comparing asymptomatic patients and symptomatic patients with more than one year between surgery and MR examination, no significant radiologic differences, including disk herniation, were found.

Return of function after spinal cord implantation of avulsed spinal nerve roots.

Avulsion of nerve roots from the spinal cord is widely regarded as an untreatable injury. However, a series of experiments in animals has shown that, if continuity is restored between spinal cord and ventral roots, axons from spinal motor neurons can regrow into the peripheral nerves with recovery of motor function. These observations were applied in the treatment of a man with avulsion of the 6th cervical (C6) to 1st thoracic roots due to brachial plexus injury. Two ventral roots were implanted into the spinal cord through slits in the pia mater, C6 directly and C7 via sural nerve grafts. Voluntary activity in proximal arm muscles was detected electromyographically after nine months and clinically after one year. After three years the patient had voluntary activity (with some co-contraction) in the deltoid, biceps, and triceps muscles. To determine whether the improvement was due to spontaneous recovery from C5, the C5 root was blocked pharmacologically, and the results indicated that the repaired roots were contributing substantially to motor function. Repair of spinal nerve roots deserves further exploration in management of brachial plexus injury.

Gadolinium-enhanced magnetic resonance imaging of 36 patients one year after lumbar disc resection.

A prospective study of 36 patients with radicular leg pain and lumbar herniation who underwent single-level disc resection is presented. Clinical follow-up was combined with a gadolinium-DPTA MRI examination, 1 year after surgery. Disc herniation was still present in eight patients and four of these did not have any significant radicular pain. Another 15 patients had a small protrusion at the site of the former herniation. Twenty-three patients showed evidence of scar tissue. The nerve root was displaced in 12 patients and was thickened in 16 patients, respectively. Clinically, 19 patients recovered from leg pain, 14 patients improved, and 3 patients remained unchanged compared with preoperative symptoms. There was no consistent correlation between postoperative back pain or radicular leg pain and MR findings.

Comparison of contrast-enhanced computed tomography and gadolinium-enhanced magnetic resonance imaging one year after lumbar discectomy.

Computed tomography (CT) and magnetic resonance imaging (MRI) with intravenous contrast were performed on a prospective group of 35 consecutive patients 1 year after surgery for disc herniation. The aim of the study was to compare the two methods in the analysis of postoperative changes. Computed tomography showed, compared with MRI, more extensive scar tissue in 12 patients and increased deformation of the dural sac in 5 patients. However, the nerve root was better delineated by MRI, and this facilitated the assessment of root thickening in 13 patients and root displacement, which could not be seen by CT in seven patients. MRI revealed four small protrusions that were not visible with CT. The two methods were found to be of equal value in regard to findings such as disc herniations and foraminal stenosis, which might influence the surgeons decision to perform repeat surgery.

A preoperative and postoperative study of the accuracy and value of electrodiagnosis in patients with lumbosacral disc herniation.

Twenty patients with a radicular syndrome, who underwent surgery for unilevel lumbosacral disc herniations verified by computed tomography were investigated with neurophysiologic tests (electromyograms, F-responses, dermatome somatosensory evoked potentials) preoperatively and 1 year postoperatively. At least one test revealed a pathologic abnormality preoperatively in 13 patients, but in 5 patients only the nerve root level corresponded to computed tomographic findings. Discordance between neurophysiologic and radiologic findings did not predict a surgical success rate. if all neurophysiologic tests were normal the outcome was significantly worse than if any of the tests showed an abnormality (P < 0.01). Four patients who were improved after surgery still had abnormal neurophysiologic findings. In conclusion, neurophysiology is not useful to diagnose the exact level of a nerve root lesion, but may reveal whether it is present. Electrodiagnosis is recommended if radiology and clinical testing conflict. If positive, it may then serve to justify surgical exploration.

High recurrence rate following aspiration of colloid cysts in the third ventricle.

Sixteen patients treated between 1969 and 1989 for a colloid cyst of the foramen of Monro by stereotactically guided aspiration (not stereotactic extirpation) were evaluated to assess the long-term outcome of the procedure. Thirteen of these patients required reoperation due to an acute comatose state, failure to achieve permanent reduction of the cyst, or symptomatic hydrocephalus. Of these 13, six were treated twice and two were treated three times by stereotactic aspiration. Five patients underwent microsurgical extirpation and three had a shunt placed following a failed aspiration. Failure of the first procedure was detected within the first 2 months after treatment in eight patients and after more than 6 years in seven. Following stereotactic aspiration, three patients experienced a temporary memory deficit and confusion and one patient suffered a central pain syndrome. Eleven of the 26 procedures were followed by a recurrence 6 to 15 years after treatment; seven recurrent cysts were detected after more than 8 years. Of the patients with recurrences, three did not undergo repeat surgery but showed an increase in cyst size at the latest follow-up examination. It is suggested that radical removal by open or stereotactically guided microsurgery is the method of choice since stereotactic aspiration fails to offer a radical or permanent treatment for colloid cysts of the third ventricle.