Incidental pituitary macroadenoma: a population-based study.

Epidemiologic analysis of incidental macroadenoma is limited to autopsy studies and case series. There are no published data about prevalence of incidental pituitary macroadenoma in living patients. The objective of this study was to determine the prevalence of incidental pituitary macroadenoma. It was designed as an observational study of cranial computed tomography reports. An urban department of veterans affairs medical center was used for the setting. The subject group consisted of 3,550 consecutive patients at the Cleveland Department of Veterans Affairs Medical Center from January 1993 to January 1996. Patients with known or suspected pituitary or parasellar disease were excluded. Cranial computed tomography reports were reviewed. Original films and medical charts of all patients with pituitary macroadenoma were reviewed. Seven patients with incidentally discovered pituitary macroadenoma that ranged from 1 cm to 2.5 cm were found; prevalence was 0.20% (95% confidence interval 0.05, 0.35%). Evidence of partial hypopituitarism was found in most patients. All patients had normal visual fields at initial examination despite the size of the tumor, but 1 of 4 had a field cut demonstrated by Goldmann perimetry. These data confirm that, although the prevalence of incidental pituitary macroadenoma is low, screening identified patients to detect deficiency of corticotropin, thyroid-stimulating hormone, and gonadotropins and to detect visual field defects is important.

Intracranial Wegener's granulomatosis.

We describe an atypical neurologic presentation of Wegener's granulomatosis (WG) with striking meningeal and cerebral involvement, responding to immunosuppressive therapy. WG may cause treatable intracranial complications in the absence of nasal or renal disease and without cerebral angiographic abnormalities, CSF pleocytosis, or a positive assay for antineutrophil cytoplasmic antibodies.

Use of the delayed mask for improved demonstration of aneurysms on intraarterial DSA.

PURPOSE: We retrospectively explored the use of the delayed mask technique for intraarterial digital subtraction angiography (IADSA) to demonstrate the anatomy of aneurysm necks. METHODS: The delayed mask technique was utilized in 22 patients who had craniotomies for aneurysms demonstrated at angiography. The operative notes were compared to the angiographic findings of both the traditionally masked IADSA and the delayed mask IADSA. In addition, an in vitro model was constructed to examine the relationship between the size of the aneurysm neck and the ability to indirectly define its anatomy by demonstrating the flow jet. RESULTS: In 12 of 22 cases, the delayed mask technique demonstrated a systolic jet that was not demonstrated by traditional subtraction techniques. In nine of 12 cases, the delayed mask technique gave more specific information regarding the size, location, and orientation of the aneurysm neck. CONCLUSION: The delayed mask technique can add important information regarding the anatomy of aneurysm without adding time or risk to the procedure.

Postinfarction seizures. A clinical study.

We retrospectively studied 90 patients with postinfarction seizures to determine the clinical features (onset, number, type), prognosis, and electroencephalographic and computed tomographic findings; we included infarctions of all etiologies. Thirty-three percent of the 90 seizures appeared early (within 2 weeks after the infarction), and 90% of the 30 early seizures appeared within 24 hours after the infarction. Seventy-three percent of the 90 seizures occurred within the first year, and only 2% occurred greater than 2 years after the infarction. Fifty-six percent of the 90 seizures were single, and status epilepticus was seen in only 8%. Early-onset seizures were more likely to be partial (57% of 30); late-onset seizures were more likely to be generalized (65% of 60). Thirty-nine percent of the 90 initial seizures recurred, and there was no significant difference in recurrence rate between early- or late-onset initial seizures. Twenty-two percent of the 90 initial seizures became multiple recurrent seizures, and we could identify a precipitating factor in 86% of the 35 recurrent seizures. The most common electroencephalographic abnormality in the 61 patients so examined was focal slowing (61%), but recurrent seizures occurred in 100% of the four patients with periodic lateralized epileptiform discharges and in 75% of the eight patients with diffuse slowing. Computed tomography in 61 patients showed that large infarctions were associated with early (p less than 0.021) and multiple (p less than 0.05) seizures. Deep infarctions on computed tomograms (cortical infarctions extending to subcortical structures) tended to cause recurrent seizures (p less than 0.057). Seizures in 88% of the 90 patients could be managed with monotherapy.

Anomalous branches of the cervical internal carotid artery: two cases of clinical importance.

Anomalous branches of the cervical portion of the internal carotid artery are rare. Reports in which these anomalous branches are of any clinical importance are even more rare. We are reporting two cases in which the anomalous branch maintained patency of the cervical portion of the proximally occluded internal carotid artery. Both patients initially had hemispheric symptoms appropriate to the affected internal carotid artery. This article details angiographic methods to demonstrate the unusual anatomic and pathologic aspects of these cases and the successful operative approach.

The relation of retinal artery occlusion and carotid artery stenosis.

We retrospectively studied 46 patients with symptomatic retinal artery occlusion and assessed the pattern and extent of carotid artery disease ipsilateral to the retinal artery occlusion. Ipsilateral internal carotid artery atherosclerotic lesions were virtually limited to the cervical arterial segment; 50% of such lesions were plaques or stenoses of less than or equal to 60%, whereas 15% of the angiograms were normal. No clinical features were significantly associated with a flow-limiting carotid stenosis of greater than 60%. Contrary to previous reports, the type of retinal artery occlusion, whether branch or central artery occlusion, was not predictive of severe underlying carotid stenosis or occlusion. Likely mechanisms of retinal artery occlusion include in situ thrombosis and emboli from carotid, and possibly cardiac, sources. Extension of thrombus from an occluded carotid artery into the ophthalmic artery did not appear to be a mechanism of retinal artery occlusion.

Periventricular white matter changes and dementia. Clinical, neuropsychological, radiological, and pathological correlation.

Forty-three patients with computed tomographic scan findings of decreased attenuation in the periventricular white matter (PVWM) region were studied. Clinical evaluation revealed presence of hypertension in 36 patients (84%) and cerebrovascular risk factors in 41 patients (95%). Unilateral or bilateral neurological deficits were present in 40 patients (93%). Neuropsychological evaluation in 27 of them revealed features of subcortical dementia. Magnetic resonance imaging in seven cases demonstrated high-intensity areas in the deep white matter region on T2-weighted imaging. Pathological evaluation in four patients revealed demyelination without inflammatory cells and infarctions in the PVWM region, lacunar infarctions in the basal ganglia and brain stem, and marked arteriosclerosis. The study indicated that most (95% in this series) of the patients with computed tomographic scan findings of decreased attenuation in the PVWM region had cerebrovascular risk factors and various neurological and neuropsychological features of subcortical dementia. Pathologically, these lesions represented areas of infarction and demyelination, along with diffuse arteriosclerosis.

MRI and CT of sellar and parasellar disorders.

Discussion of the anatomy of the parasellar region focuses on the optic chiasm and its relationship to surrounding structures. CT and MRI are valuable tools in the imaging of these regions. This article provides a brief review of the technique of CT and MRI with visualized anatomic structures of these areas. A closer look at how CT and MRI are used to delineate the different pathologic processes of the sellar and parasellar regions then follows.

Optic nerve tumors: role of magnetic resonance imaging and computed tomography.

Localization and pathologic diagnosis of optic nerve tumors have been greatly improved by high resolution computed tomography and magnetic resonance imaging. Radiologic differentiation of the most common tumors of the optic nerve (meningioma and glioma) can be made by using these new imaging modalities. Early diagnosis of optic nerve lesions has resulted in better prognosis and surgical outcome.

Hydrocephalus following iophendylate injection myelography with spontaneous resolution: case report and review.

A 62-year-old patient developed severe adhesive spinal arachnoiditis and hydrocephalus with papilledema following iophendylate injection myelography. Papilledema and hydrocephalus resolved spontaneously. The possible mechanism for hydrocephalus is discussed and the literature reviewed.

Importance of metrizamide CT for evaluation of the thoracic spine.

Post-metrizamide myelographic CT of the area of interest is indicated in cases in which myelography is normal, and also in cases in which myelographic findings alone cannot explain the patient's symptoms. Obtaining early and 4-6 hour delayed CT is of great importance for the detection of syringomyelia and cystic lesions of the cord. In cases of congenital anomalies, additional information can be obtained by this method. This paper presents our experiences at Loyola University Hospital.

Toxemia of pregnancy: cerebral CT findings.

Four patients with pregnancy-induced hypertension (preeclampsia-eclampsia) and neurological dysfunction unrelated to intracranial hemorrhage, cerebral venous thrombosis, or preexisting neurological disorder had cranial CT performed during their hospitalization. Three patients had diffuse white matter hypodensities with associated mass effect. The fourth patient had bilateral, asymmetric hypodensities confined to the basal ganglia. Computed tomography is useful in establishing an early diagnosis of the complicating neurological disorder as well as in providing a better understanding of the physiopathological changes seen in the brain in this condition.

Long survival of primary cerebral lymphoma with progressive radiation necrosis.

A 56-year-old man lived 8 years after excision and irradiation of a primary cerebral lymphoma. Delayed radiation necrosis caused progressive neurologic deterioration and probably his steroid-responsive episodes of obtundation. Vasogenic edema induced by radiation may account for the latter. An incidental extraneural lymphoma was found postmortem without evidence of CNS lymphoma.

Cerebrospinal fluid rhinorrhea with bilateral intradiploic epidermoid tumors: a case report.

Bilateral large intradiploic epidermoid tumors of the occipital bone presented clinically with CSF rhinorrhea are presented.

Cranial subdural hematoma following lumbar myelography.

A case of cranial subdural hematoma after lumbar myelography is reported. The literature of this unusual complication of lumbar myelography is reviewed and the possible mechanism is discussed briefly.

Computed tomography of the face and paranasal sinuses: Part I. Normal anatomy.

Computed tomographic (CT) scanning of the face and sinuses has improved markedly with modern equipment and methods. Expertise in facial and sinus anatomy as seen by CT is invaluable to the clinician. A review of normal CT anatomy is presented as a basis for diagnosing pathologic conditions.