Ability of navigated 3D ultrasound to delineate gliomas and metastases--comparison of image interpretations with histopathology.

BACKGROUND: The objective of the study was to test the ability of a 3D ultrasound (US) based intraoperative imaging and navigation system to delineate gliomas and metastases in a clinical setting. The 3D US data is displayed as reformatted 2D image slices. The quality of the displayed 3D data is affected both by the resolution of the acquired data and the reformatting process. In order to investigate whether or not 3D US could be used for reliable guidance in tumour surgery, a study was initiated to compare interpretations of imaged biopsy sites with histopathology. The system also enabled concomitant comparison of navigated preoperative MR with histopathology. METHOD: Eighty-five biopsies were sampled between 2-7 mm from the tumour border visible in the ultrasound images. Biopsies were collected from 28 operations (7 low-grade astrocytomas, 8 anaplastic astrocytomas, 7 glioblastomas and 6 metastases). Corresponding cross-sections of preoperative MR T1, MR T2 and intraoperative US were concomitantly displayed, steered by the biopsy forceps equipped with a positioning sensor. The surgeons' interpretation of the images at the electronically indicated biopsy sites were compared with the histopathology of the samples. FINDINGS: The ultrasound findings were in agreement with histopathology in 74% (n = 31) for low-grade astrocytomas, 83% (n = 18) for anaplastic astrocytomas, 77% (n = 26) for glioblastomas and 100% (n = 10) for metastases. Excluding irradiated patients, the results for glioblastomas improved to 80% concurrence (n = 20). As expected tumour cells were found in biopsies outside the US visible tumour border, especially in low-grade gliomas. Navigated 3D US have a significantly better agreement with histopathology than navigated MR T1 for low-grade astrocytomas. CONCLUSION: Reformatted images from 3D US volumes give a good delineation of metastases and the solid part of gliomas before starting the resection. Navigated 3D US is at least as reliable as navigated 3D MR to delineate gliomas and metastases.

Attachment security and parental bonding in adults with obsessive-compulsive disorder: a comparison with depressed out-patients and healthy controls.

OBJECTIVE: This study examines concurrent associations of attachment security, psychopathology and recollections of early parental interactions, in adults with obsessive-compulsive disorder (OCD), depression, and in healthy controls. METHOD: Thirty-six out-patients with OCD, 16 depressed out-patients and 26 controls were asked to fill out the Revised Adult Attachment Scale and the Parental Bonding Instrument (PBI). RESULTS: OCD and depressed groups were more insecure than controls. The depressed group recalled less caring mothers than the OCD group, while the OCD group was indistinguishable from controls on PBI measures. Married status was associated with greater security, but also with recollections of greater parental control, and lower maternal care. CONCLUSION: OCD and depressed groups demonstrated greater attachment insecurity than controls. No clear relationship emerged between security and PBI recollections. The PBI may not measure aspects of early interactions essential for later attachment security, or recollections may be biased according to diagnosis or attachment style.

Is monochorionic twinning a risk factor for focal cortical dysgenesis?

OBJECTIVES: Various genetic and acquired factors have been proposed as being etiologically important in cortical dysgenesis. It has been suggested that fetal, developmental abnormalities may be induced by transient, circulatory instability in monochorionic twinning due to feto-fetal transfusions. We report the discordant occurrence of a malformation of cortical development in monozygotic, monochorionic twins, and discuss the findings and possible pathogenetic mechanisms. MATERIAL AND METHODS: The twins were females, 30 years of age, one of them suffering from uncontrolled localization-related epilepsy. Neurological deficits or mental retardation were not present. Genetic analysis, brain MRI, and a neuropsychological test battery were carried out. RESULTS: DNA analysis verified monozygocity. MRI showed a unilateral grey matter heterotopion and a contralateral temporal arachnoid cyst in the affected twin. Neuro-psychological assessment revealed no corresponding focal cognitive deficits, but an overall slightly lowered performance in the affected twin. CONCLUSION: Discordant affection of focal, cortical dysgenesis in monozygotic twins creates a particular opportunity to assess the consequences of such a disorder. The fact that only a mild generalized influence on cognitive functioning was demonstrated in this case, is possibly due to the plasticity of the fetal brain. According to current, obstetrical literature, the unique embryology of monochorionic twinning may predispose to vascular events in early fetal life. As ultrasound studies now indicate that a large proportion of pregnancies start out as twin products, we hypothesize that the "vanishing twin" syndrome and its potential hemodynamic hazard to the surviving fetus may be an etiological factor in malformations of cortical development, even in singletons.

[Medullary compression in metastatic cancer]. / Medullakompresjon ved metastatisk kreftsykdom.

Cancer patients with spinal cord compression may develop irreversible neurological deficit. The clinical picture implies back pain and subsequent neurological deficit. There is always a danger of rapid deterioration of the patient's condition. If spinal cord compression is suspected, the case is an emergency. MRI should be preferred in the diagnostic work-up, and corticosteroids be administered promptly. Radiation therapy or surgical treatment should be started as soon as possible. Patient outcome is related to the degree of neurological deficit at the start of treatment.

Autism and other pervasive developmental disorders: exploring the dimensional view.

OBJECTIVE: To examine empirical data on children with autistic disorder (AD), Asperger's disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) for continuities or distinguishing features between disorder and to see to what extent the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) diagnostic criteria-reflect observed data. METHOD: Studies were identified in 4 ways. 1)A Medline search from 1976 to the present of articles with the key words autism, pervasive developmental disorder, autistic spectrum disorder, and Asperger; of these articles, those with mesh headings or textwords "cluster," which identified cluster analyses deriving pervasive developmental disorder (PDD) subtypes, were retained 2) The Journal of Autistic and Developmental Disorder from 1990 to the present was hand-searched to identify other empirically derived studies on diagnosis, prevalence, classification, and validity of PDD subtypes. 3) Key review articles were searched for their references. 4) The references of all identified articles were searched. RESULTS: Eight cluster studies were retained for their relevance to diagnostic issues, as were 7 empirically derived studies delineating clinic characteristics of children will AD, Asperger's syndrome, or PDD-NOS. Data suggests that children with PDD may fit into 1 of 2 overlapping groups, including a lower-functioning group with greater developmental compromise, social aloofness, and a greater number of autistic symptoms and a higher-functioning group with higher IQ, fewer autistic symptoms, and more prosocial behavior. The PDD subtype resemble each other and can be seen as existing o a continuum, differing only by degree of impairment. CONCLUSION: Children exhibiting the triad of autistic impairments can be seen as suffering from disorders on a PDD continuum. While the DSM-IV does identify a lower-functioning autistic group (AD), the higher-functioning group is less well served. Asperger's disorder as defined in the DSM-IV is not clearly distinguishable from AD and PDD-NOS, and the PDD-NOS subcategory is not operationalized. Further research is required to elaborate criteria for the higher-functioning PDD group, and measures related to etiology, outcome, and treatment response may help determine which diagnostic criteria can meaningfully separate one disorder from another.

Focal, continuous spikes suggest cortical developmental abnormalities. Clinical, MRI and neuropathological correlates.

OBJECTIVES: Widespread use of MRI now gives us increased insights into the different expressions of malformations of cortical development (MCD). The heterogeneity of these disorders are reflected by their varied clinical and neuroimaging features. Characteristic and intense scalp EEG abnormalities have been described in some patients. MATERIAL AND METHODS: We report the MRI and clinical findings of 3 adult patients (age 32-36) with a peculiar EEG pattern of distinct, localized, fast, continuous spiking. These patients represent all patients with such EEG findings that have been recognized by the first author during 9 years. RESULTS: MRI showed MCDs in all, respectively hemimegalencephaly, a subcortical heterotopion, and a focal cortical dysgenesis. The EEG findings had been stable since childhood and were posteriorly located. Two patients had fairly well controlled epilepsy in adult age. The third patient was incapacitated by persistent seizures and was treated with surgery. Histologically cortical dysplasia with neuronal clusters was found in this patient. Variable degrees of cognitive dysfunction were present in all. CONCLUSION: Focal, continuous, fast spiking is an unusual scalp EEG pattern. It is not an inevitable sign of severe epilepsy. It may suggest an MCD. It is not yet clear to what extent such findings are predictive of a dysgenetic etiology of epilepsy.

Lhermitte-Duclos disease and giant meningioma as manifestations of Cowden's disease.

A 43-year-old man with synchronous occurrence of Lhermitte-Duclos disease (dysplastic gangliocytoma of the cerebellum) and a giant meningioma with subcutaneous infiltration is reported. Subsequent examinations revealed typical manifestations of Cowden's disease (multiple hamartomaneoplasia syndrome), i.e. mucocutaneous lesions and increased head circumference. Our findings support the view that there is a correlation between Lhermitte-Duclos disease and Cowden's disease. We conclude that all patients with Lhermitte-Duclos disease should be thoroughly examined with regard to Cowden's disease, which necessitates lifelong follow-up with screening for neoplasia in various organ systems. The occurrence of both Lhermitte-Duclos disease and a meningioma as part of the Cowden's symptom complex is very rare and to our knowledge only one case with this combination of lesions has previously been reported.

Idiopathic normal pressure hydrocephalus: the CSF tap-test may predict the clinical response to shunting.

A follow-up study was performed in nine patients with idiopathic normal pressure hydrocephalus (NPH) 37 months (mean) after shunting and 10 non-operated controls with comparable degrees of ventricular enlargement, gait disorder, and dementia. Five operated patients vs. no controls reported sustained general improvement (p < 0.02). Objectively improved gait at follow-up (compared with preoperative status) was found in five of the six tested NPH-patients vs. none of the controls (p < 0.005). Improved gait and/or psychometric function was found in four of six NPH vs. none of eight control patients (p < 0.02) after drainage of 40 ml cerebrospinal fluid (CSF tap-test). Improved gait during the CSF tap-test predicted continued improvement at follow-up. Temporal horn size was the only radiological variable which showed a (moderate) positive correlation with resistance to CSF absorption and rate of pressure increase. The size of the third ventricle diminished in parallel with clinical improvement.

Perianal fistulas: use of MR imaging for diagnosis.

PURPOSE: To evaluate use of magnetic resonance (MR) imaging with saline solution as contrast agent in diagnosis of perianal fistulous disease. MATERIALS AND METHODS: Spin-echo intermediate-, T2-, and T1-weighted images were obtained before and after instillation of saline solution into anal fistulas in 12 of 16 consecutive patients. In four patients without secretory fistulas, images were obtained without contrast enhancement. RESULTS: Fistulous tracts were found in 13 patients, fluid cavities in 13, secondary fibrotic tracts in two, and normal perirectal tissue in one. The extent of fistulas and fluid collections was better delineated or more conspicuous on contrast-enhanced images in eight and 10 examinations, respectively, in part due to expansion of collapsed portions of the fistulous system. T2-weighted images were sufficient for diagnosis. CONCLUSION: MR imaging with saline solution as contrast agent may improve visualization of fistulas and their relationship to normal anatomic structures in patients with complex fistulous systems with relatively sparse secretion.

ACTH and TSH producing ectopic suprasellar pituitary adenoma of the hypothalamic region: case report.

A 34-year-old woman with a long-term history of amenorrhoea, headache and visual disturbances was operated for a hypothalamic tumor which could be completely removed. Postoperatively the patient developed a transient SIADH-syndrome and deep vein thrombosis; otherwise the clinical course was uneventful. There has been no sign of tumor recurrence at a follow-up period of fifteen months. Histological examination of the tumor revealed an ectopic pituitary adenoma with production of ACTH and TSH shown by immunohistochemistry.

[Oral magnetic particles as an MR contrast medium for the gastrointestinal tract]. / Orale magnetische Partikel als MR-Kontrastmittel für den Gastrointestinaltrakt.

The authors summarise their experience of four clinical studies with a negative oral contrast agent for magnetic resonance imaging of the abdomen and pelvis. 140 patients were enrolled in the studies. These were partly comparative studies pre- and post-contrast, partly at 0.5 and 1.5 T, partly pre-injection and post-injection of glucagon. All patients received 800 ml of a suspension of oral magnetic particles "OMP". The distribution of this contrast agent was homogeneous throughout the entire GI tract. A complete or partial signal void was observed in all patients in T1, T2-, and intermediately weighted images. Generally, diagnostic information was higher after contrast. Artifacts caused by peristalsis and movement of the diaphragm were fewer after contrast. After contrast metallic artifacts were observed in a minority of patients. Adverse events after contrast were minimal; they included nausea and vomiting.

Gadodiamide injection and gadopentetate dimeglumine. A double-blind study in MR imaging of the CNS.

A double-blind, randomized parallel phase III study in MR imaging of the central nervous system was conducted to compare the safety and diagnostic utility of gadodiamide injection and gadopentetate dimeglumine at a dose of 0.1 mmol/kg b.w. in 60 adult patients. Seven patients in the gadodiamide injection group experienced 10 adverse events, 5 of the events possibly related to the contrast agent. In the gadopentetate dimeglumine group 5 patients reported 3 contrast agent-related adverse events out of 8 events. All events were transient and required no treatment. Seven incidents of patient discomfort, and some minor changes in vital signs and laboratory parameters were of no clinical concern. Contrast enhancement was observed in 60% and 44% of the patients with structural abnormalities in the gadodiamide injection group and gadopentetate dimeglumine group, respectively. No difference in overall efficacy was observed. Gadodiamide injection was found to be a safe and effective contrast agent.

Cerebral magnetic resonance imaging and cerebral computerized tomography for patients with solvent-induced encephalopathy.

To compare the results of cerebral magnetic resonance imaging (MRI) and computerized tomography (CT) for patients with solvent-induced encephalopathy, a parallel study was performed with nine patients. The diagnosis had been given three to five years earlier on the basis of relevant exposure to solvents, findings on neuropsychological tests, a neurological examination, and cerebral CT. There was no progression of pathological lesions from the first to the second CT examination. Four patients with atrophy in the CT examination also had atrophy in the MRI examination. In addition three patients with normal CT findings showed atrophy in the MRI examination. It was concluded that MRI should be the modality of choice whenever diagnostic imaging is necessary in the clinical workout of patients with diagnosed or suspected solvent-induced encephalopathy.

[Atlanto-axial rotatory fixation. Current diagnosis in torticollis]. / Atlantoaksial rotasjonsfiksasjon. Aktuell diagnose ved torticollis.

Atlantoaxial rotatory fixation is a disorder which must be considered in persistent torticollis. The disorder occurs mainly in children and young adults. The usual etiological factors are traumas or infections of the upper respiratory tract, but the onset may also be spontaneous. The pathogenesis of the fixation is poorly understood. We describe three patients with atlantoaxial rotatory fixation and demonstrate the usefulness of computerized tomography in the diagnosis of this condition. We recommend a posterior atlantoaxial fusion if conservative treatment fails to reduce the rotatory fixation.

Lumbar iohexol myelography and diagnostic lumbar puncture. Headache and associated side effects in relation to neurological signs and diagnosis, previous mental symptoms and pain history.

Various possible risk factors for postlumbar puncture (and postiohexol-myelographic) headache and associated side effects were analysed. Headache and nausea occurred significantly more often in patients without clinical findings than in those with findings. We found significantly different incidences of severe headache and nausea between diagnostic subgroups after a lumbar puncture. The greatest headache incidence was found in patients without a definite neurological diagnosis, while nausea occurred most frequently in patients with various painful disorders. Following iohexol myelography, nausea occurred most often in patients who had a history of previous mental symptoms and in patients with a history of previous headache disorders. Mental symptoms were more frequently reported in patients who also had experienced mental symptoms previously. The relationship between side effects and negative clinical findings was stronger than the relationship between side effects and previous mental symptoms.

Side effects after lumbar iohexol myelography. Relation to radiological diagnosis, sex and age.

Side effects of iohexol lumbar myelography have been analyzed with respect to the influence of the type of radiological abnormality, sex and age in a group of 200 patients. Headache, postural headache, nausea and back/leg pain were significantly more frequent in patients without definite radiological abnormalities. Postural headache, nausea, dizziness and mental symptoms were more frequent in women, while headache, postural headache, nausea, dizziness, minor mental symptoms (i.e. anxiety or depression) and pain became less frequent with age. This pattern is similar to that reported after lumbar puncture. Young women without definite clinical signs of nerve root lesions probably have the greatest risk of experiencing side effects after iohexol lumbar myelography.

[Surgical treatment of renal artery stenosis]. / Kirurgisk behandling av nyrearteriestenose.

Renal artery stenosis may be the cause of hypertension and reduced renal function. The aim of surgical treatment is to eliminate or reduce the hypertension and to preserve or improve kidney function. At our hospital the standard surgical procedure is aortorenal bypass. We present the results of this procedure in the treatment of 23 patients (27 bypasses) during a five-year period. During the same periode nine patients were treated with percutaneous transluminal renal angioplasty. Arterial reconstruction of the renal artery is a relatively simple and cost-effective treatment. Furthermore, the rate of postoperative complications is low.

Side effects after ambulatory lumbar iohexol myelography.

Side effect incidences after ambulatory (22G needle and two h bed rest) and after non-ambulatory (22 and 20G needles and 20 h bed rest) lumbar iohexol myelography have been estimated and compared. Headache incidence was significantly greater in ambulatory (50%, n = 107) as compared to non-ambulatory myelography (26%, n = 58). Headaches in the ambulatory group tended to be of shorter duration and the difference between severe headaches in ambulatory and non-ambulatory groups was not significant. Serious adverse reactions did not occur and none of the ambulatory patients required readmission because of side effects. The headache was predominantly postural and occurred significantly earlier in the ambulatory group. Headache incidence was significantly greater after 20G needle myelography (44%, n = 97) as compared to 22G needle iohexol myelography (26%, n = 58). The results supports the hypothesis that CSF leakage is a major cause of headache after lumbar iohexol myelography.