White matter lesions in euthymic patients with bipolar disorder.

OBJECTIVE: We aimed to quantify both load and regional distributions of hyperintensities on magnetic resonance imaging (MRI) in prospectively verified euthymic bipolar patients and matched controls. METHOD: Cerebral hyperintensities on T2, proton density and fluid-attenuated inversion recovery (FLAIR) MRI were compared between 48 bipolar and 47 control subjects using semi-quantitative rating scales. RESULTS: Bipolar subjects had more severe frontal deep white matter lesions (DWML). Hyperintensity load was independent of age in bipolar patients but increased with age in controls. Global prevalence and severity of hyperintensities did not differ between groups. Exploratory analysis showed DWML in excess in the left hemisphere in bipolar subjects but not in controls. CONCLUSION: Findings are consistent with clinical, particularly some neurocognitive, features of bipolar disorder and implicate fronto-subcortical circuits in its neurobiology. They more probably reflect a trait abnormality or illness scar rather than a mood state-dependent finding. Processes other than ageing and vascular factors may underlie their development.

Mechanisms of dyspnoea relief and improved exercise endurance after furosemide inhalation in COPD.

BACKGROUND: This study examined the effects of inhaled furosemide on the ventilatory and perceptual response to high-intensity constant-load cycle exercise in chronic obstructive pulmonary disease (COPD). METHODS: In a randomised, double-blind, placebo-controlled, crossover study, 20 patients with COPD (mean (SD) forced expiratory volume in 1 s 45 (15)% predicted) received either nebulised furosemide 40 mg or placebo on two separate days. Thirty minutes after each treatment, patients performed pulmonary function tests and a symptom-limited cycle exercise test at 75% of their maximum incremental work rate. Changes in spirometry, plethysmographic lung volumes, dynamic operating lung volumes, ventilation, breathing pattern, cardiovascular function, dyspnoea intensity and exercise endurance time were compared between treatments. RESULTS: Compared with placebo, treatment with furosemide resulted in a mean (SD) decrease in dyspnoea intensity at the highest equivalent exercise time (ie, isotime for each patient) of 0.9 (1.0) Borg units (p<0.01) and an increase in exercise endurance time of 1.65 (0.63) min (p<0.05). These improvements were associated with increases in dynamic inspiratory capacity, tidal volume and mean tidal expiratory flow rates at isotime (p<0.01). The eight patients whose exercise endurance time improved by >1 min had greater changes in operating lung volumes (p<0.05), submaximal oxygen pulse (p<0.05) and oxygen uptake (p = 0.05) than those in whom exercise endurance time did not improve. CONCLUSION: Alleviation of exertional dyspnoea after single-dose furosemide inhalation in COPD is multifactorial but improvements in dynamic ventilatory mechanics are contributory in some individuals.

White matter lesions and season of birth of patients with bipolar affective disorder.

OBJECTIVE: It is established that patients with bipolar disorder have an excess of births in winter or early spring. The authors investigated a link between season of birth and white matter lesions with magnetic resonance imaging (MRI). METHOD: T(2)-weighted and proton density MRI scans were examined for 79 patients with bipolar disorder (DSM-IV) for the presence of deep subcortical and periventricular white matter lesions. The birth seasons of patients with white matter lesions were compared with those of the general population. RESULTS: Thirteen subjects exhibited deep subcortical white matter lesions, of whom nine (69.2%) were born in the winter months (January to March). Seven of these patients remained symptomatic, despite adequate treatment for more than 2 years. CONCLUSIONS: Birth season, illness outcome, and deep subcortical white matter lesions appear to be closely linked. Deep subcortical white matter lesions may be a marker of a toxic or infective insult in utero.

Cerebral white matter lesions in bipolar affective disorder: relationship to outcome.

BACKGROUND: Twenty per cent of patients with bipolar affective disorder suffer an illness that responds inadequately to treatment and has a poor outcome. Many patients, but not all, with bipolar disorder show white matter abnormalities on T(2)-weighted magnetic resonance imaging (MRI). AIMS: To explore the hypothesis that white matter abnormalities on MRI are seen more frequently in subjects whose illness has a poor outcome compared with those with a good outcome or controls. METHOD: Two groups of age- and gender-matched patients with bipolar disorder (14 with a good outcome and 15 with a poor outcome) and 15 controls, aged 20-65 years, were studied. Axial T(2)-weighted MRI scans were examined for the presence and severity of white matter abnormalities. RESULTS: Significantly more poor outcome group members had deep subcortical punctate, but not periventricular, white matter hyperintensities than the good outcome group (P:=0.035) or controls (P:=0.003) and these abnormalities were of greater severity (P:=0.030 and P:<0.014, respectively). CONCLUSIONS: Subcortical white matter lesions are associated with poor outcome bipolar disorder.

Structural and functional abnormalities in elderly patients clinically recovered from early- and late-onset depression.

BACKGROUND: Structural and functional brain changes have been described in elderly patients with unipolar affective disorder. Changes appear to be more marked in patients with late-onset depression, but the reversibility of such changes after clinical recovery is not known. METHODS: Magnetic resonance imaging, electroencephalography (EEG), and cognitive tests were performed in 23 elderly patients (mean age 66.5 years) clinically recovered from major depression. Twelve had late-onset depression (first episode over 55 years of age); 11 had early onset (first episode before 50 years). EEG and cognitive testing were also performed on 15 control subjects. RESULTS: Patients with late-onset depression had larger third and lateral ventricles, increased ventricular-brain ratio, and greater frequency and severity of subcortical white matter lesions than those with early onset. There was no difference between early- and late-onset patients in EEG and cognitive measures, but compared with controls patients showed significant changes in EEG evoked potentials and increased slow-wave activity, slowed reaction times, and global impairments in cognitive function. CONCLUSIONS: These results suggest that structural changes are greater in patients with late-onset depression, and that EEG and cognitive impairments persist after recovery, regardless of age of onset of depression, and are independent of structural changes.

Cerebrotendinous xanthomatosis in two sisters: case reports and MR imaging.

Cerebrotendinous xanthomatosis is a rare inherited disorder of bile acid metabolism producing xanthomata and severe, progressive neurological deficits. In spite of the rarity of the condition it is important because it is treatable: the neurological deterioration can be halted and in some cases reversed.

The radiological features of hemimegalencephaly including three cases associated with proteus syndrome.

We report the radiological appearances of 5 children with hemimegalencephaly. There are few reports of this rare condition in the radiological literature. Two of the children have hemimegalencephaly as an isolated finding while the other three have Proteus syndrome. Four children have seizures which commenced within the first 6 months of life and two of these subsequently required hemispherectomy. In addition to the typical radiological features of hemimegalencephaly there was a high incidence of other brain anomalies. These include hypoplasia of the corpus callosum and crus cerebri, grey and white matter calcification and cortical migration/organisational disorders.

Changes in tonsillar bacteriology of recurrent acute tonsillitis: 1980 vs. 1989.

Recurrent acute tonsillitis is a common problem. Despite this, there still remain many controversies regarding aetiology and correct management. The tonsillar microflora of 33 children with recurrent acute tonsillitis studied in 1980 and 58 patients studied in 1989 is presented. A comparison of the microbiology in the two periods studied a decade apart suggests that the pathogenic profile is changing. Haemophilus influenzae increased from 39 to 62% in the deep tonsillar tissue in the decade. There was a concomitant increase in incidence of Staphylococcus aureus from 6 to 40% of cases. In the same interval, mixed microflora increased from 18 to 52%. Anaerobic organisms were isolated in insignificant numbers. Unique to this study, 44% of H. influenzae isolates in 1989 were beta lactamase producers, increasing from only 2% in 1980. All of the S. aureus were beta lactamase producers. In the majority, the throat swabs grew only organisms commensal to the upper respiratory tract however, the deep tonsillar tissue excised at tonsillectomy carried significant growths of pathogenic organisms confirming the inadequacy of the superficial tonsillar swab as an indicator of treatment.

Cerebellar astrocytoma presenting as a syringomyelic syndrome.

Cerebellar astrocytomas comprise about 36% of posterior fossa tumors in childhood. Such tumors presenting with hemorrhage have been reported, but in such cases, the location of the lesion was clinically obvious. This 16-year-old boy presented with a syringomyelic syndrome resulting from hemorrhage in the tumor causing compression of the upper cervical spinal cord. Such a case has not been previously recorded. Possible mechanisms leading to this syndrome are discussed and the relevant literature reviewed.

A prospective comparison of iotrolan, iohexol and iopamidol for lumbar myelography.

The provisional results are presented of a comparative blind trial of iotrolan, iohexol and iopamidol for lumbar myelography. The aim of the trial was to assess the relative safety, tolerance and radiologic efficacy of the media. From the data available to date the incidence of side effects is similar for all three substances. Iotrolan does not provide specific imaging advantages.

Subarachnoid hemorrhage in childhood and adolescence.

The authors have reviewed 167 cases of subarachnoid hemorrhage (SAH) occurring in patients aged 20 years and younger in a 23-year period. The modes of presentation and etiology of SAH are similar in childhood and adolescence and in the adult population, but there was a different incidence of the specific pathology producing the bleeding in this series. Twenty-six percent of cases were due to bleeding arteriovenous malformations, 52% were due to ruptured aneurysms, and in 19% no cause was found. Aneurysms in this young age group differed in several important respects from those in the adult population: there was a male predominance, a higher incidence of internal carotid bifurcation aneurysms was seen, and multiple aneurysms were encountered less commonly.

Posterior circulation aneurysms. Results of direct operations.

Twenty-eight patients with aneurysms of the posterior circulation were managed by direct operations, 53.6% of these being done within 14 days of a subarachnoid hemorrhage. Transvenous cardiac pacing was used in 4 of the 13 patients with aneurysms of the basilar bifurcation in order to produce a short period of profound hypotension while final dissection and clip application was performed. There were nine patients with posterior-inferior cerebellar artery/vertebral-junction aneurysms, the only one dying having a large aneurysm. The operative technique used in the majority of the 13 patients with basilar bifurcation aneurysms involved subtotal temporal lobectomy, and the operative exposure so obtained was excellent. Five patients died, one of whom rebled from an aneurysm of the basilar artery origin that could only be wrapped, the total mortality being 17.9%. Seventeen (74%) of the 23 survivors were assessed as showing good results; 5 (22%) as showing fair results, and only 1 (4%) as showing a poor result.

Intracranial calcification in survivors of childhood medulloblastoma.

Computerised tomography scans of the brain have been performed on 5 children who have survived at least 5 years after treatment with surgery and radiotherapy for medulloblastoma. Intracranial calcification of varying degrees of the basal ganglia and of the frontal and parietal cortex was detected in the 3 children who were irradiated under age 5 years.

A randomized blind trial of iopamidol (Niopam) and Metrizamide (Amipaque) in lumber radiculography.

A randomised blind trial comparing Iopamidol (Niopam) and Metrizamide (Amipaque) for lumbar radiculography was performed in 100 patients. Significantly more patients receiving Metrizamide complained of having severe headaches (P less than 0.05) and vomiting (P less than 0.05). There was no difference in quality of the radiculograms.

Nontraumatic cerebrospinal fluid rhinorrhoea from a fistula between the trigeminal cistern and sphenoid sinus.

The radiological appearances of the trigeminal cistern on metrizamide cisternography and metrizamide CT cisternography are described. The frequent demonstration of this cistern on metrizamide cisternography is emphasised. A case of nontraumatic CSF rhinorrhoea produced by a CSF leak between the trigeminal cistern and the sphenoid sinus is described.

Metrizamide cisternography in pituitary and juxtapituitary lesions.

Seventy-five suprasellar metrizamide cisternograms were obtained, 25 in normal individuals who had had cervical myelography and 50 in patients with pituitary or juxtapituitary lesions. The technique accurately delineates a suprasellar extension of a small or moderate-sized pituitary lesion and usually shows its relationship to the optic chiasm. Large suprasellar masses, however, are not well visualized. 'Empty sellae' are readily demonstrated and have a high incidence in both normal individuals and those with pituitary tumors. This procedure can be supplemented by metrizamide CT cisternography and is simpler to perform and often better tolerated by patients than is pneumoencephalography.

Myelography with metrizamide in occult spinal dysraphism.

The initial experiences with metrizamide (Amipaque) in cases of spinal dysraphism are described. The technique, myelographic appearance and adverse reactions are discussed. The results have been promising and it is believed that this contrast medium will provide more accurate diagnostic information. However, further experience is necessary and in particular correlation with surgical findings.

The radiology of thoracic disc protrusion.

The radiological features of 20 surgically proven thoracic disc protrusions are reviewed. In 15 (75%), characteristic plain film changes were found to be very helpful in making the correct diagnosis. Calcified disc material in the spinal canal was clearly demonstrated in 11 (55%) cases, and this, in association with linear calcification in the adjacent disc space, has been shown to be diagnostic of the condition. At myelography, central protrusions (55%) were found to be predominant, while lateral protrusions were uncommon. The differential diagnosis of a calcified lesion in the spinal canal includes thoracic disc protrusion, osteochondroma and meningioma.

Radiology in the diagnosis of colloid cysts of the third ventricle.

A series of 38 cases of colloid cyst of the 3rd ventricle is described in most of whom the diagnosis, important for curative surgery, was made radiologically. The most useful investigative technique was pneumography, by which the tumour was outlined in almost all cases. The lateral "hanging head" projection generally demonstrated the lesion most satisfactorily. Care in manipulating air introduced at ventriculography through the foramina of Monro into the 3rd ventricle was frequently rewarded by clear definition of the tumour. In more than one-third of the cases, the lateral plain skull radiograph showed truncation of the dorsum sellae indicative of chronic obstructive hydrocephalus, and, in the large majority of these, pneumography confirmed that the 3rd ventricle, rather than the interventricular foramen, was the site of obstruction to the drainage of cerebrospinal fluid. Carotid angiography, showing hydrocephalus, and in the same cases elevation and lateral displacement of the anterior portion of the internal cerebral veins yielded strong supportive evidence. Vertebral angiography was less specific, and isotope scanning was quite unhelpful.