Effects of 8-wk alpha-glucosidase inhibition on metabolic control, C-peptide secretion, hepatic glucose output, and peripheral insulin sensitivity in poorly controlled type II diabetic patients.

Miglitol (BAYm 1099), an alpha-glucosidase inhibitor, reduces the postprandial increase of blood glucose and serum insulin levels in type II (non-insulin-dependent) diabetes mellitus, as shown in short-term studies. In this study, the effects of long-term miglitol treatment on metabolic control, C-peptide secretion, hepatic glucose output, and peripheral insulin sensitivity (euglycemic clamp) were tested in 15 type II diabetic patients (8 receiving insulin, 7 receiving oral hypoglycemic agents). For 8 wk they received either miglitol (300 mg/day) or placebo with a double-blind crossover design that had a 4-wk washout period between treatments. Miglitol therapy induced a reduction of postprandial blood glucose levels (miglitol compared with placebo; areas under the curve; P less than .002), whereas fasting blood glucose levels were not influenced. Miglitol caused a slight reduction of glycosylated hemoglobin levels (mean +/- SE miglitol and placebo 9.50 +/- 0.3 and 10.0 +/- 0.4%, respectively; P less than .05), which was more pronounced in insulin-treated patients. Miglitol caused a reduction of postprandial C-peptide increase (P less than .03). Hepatic glucose output (both in the basal state and during euglycemic clamp conditions) and peripheral insulin sensitivity were not influenced by miglitol therapy. Specific side effects were observed in 11 patients; in 6 patients only to a moderate degree. Long-term miglitol treatment induces a persistent reduction of postprandial blood glucose increase. This effect is more pronounced in type II diabetic patients on insulin therapy, which can cause a moderate improvement of overall metabolic control.

Clinical and angiographic features of carotid circulation thrombus.

We studied five patients with intraluminal carotid thrombus visualized by angiography. The distinctive clinical features included the following: thrombus formation without significant atherostenosis; peripheral and cerebral arterial thrombosis; step-wise evolution of cerebral and/or peripheral signs over a period of days to several weeks; clotting tendency despite heparin anticoagulation; and carotid or iliac artery thrombosis after thrombo-endarterectomy. These unusual features serve to identify an uncommon subgroup of stroke patients with large artery thrombosis. Pathogenesis was not established. Coagulopathy with elevated factor VIII levels was the suspected mechanism.

Auscultation of cervical and ocular bruits in extracranial carotid occlusive disease: a clinical and angiographic study.

The clinical and angiographic features of cervical and ocular bruits were correlated in 50 consecutive patients with severe extracranial internal carotid artery occlusive disease. Cervical bruits, generally localized to the carotid bifurcation, were highly associated (P = 0.004) with "tight" (residual lumen less than or equal to 2 mm) internal carotid artery stenosis, but significantly less often with a widely patent or occluded internal carotid artery. Angiographic features of a "slow-flow" state through a patent, but "tight" stenosis were identified as the apparent explanation for the absence of bruit in some patients. A unilateral ocular bruit contralateral to the side of internal carotid artery occlusion occurred in 9 of 10 patients, more often than an associated cervical bruit, and was interpreted as a sign of augmentation flow.

The association of cerebral aneurysms, infundibula, and intracranial arteriovenous malformations.

Intracranial arteriovenous malformations (AVMs) are congenital communications between the cerebral arteries and veins without an intervening capillary network. The association of the malformations with other vascular lesions such as intracranial aneurysms has previously been reported. We have reviewed 132 consecutive patients with intracranial AVMs evaluated angiographically at New England Medical Center. In addition to the expected high incidence of saccular aneurysms, a high incidence of arterial infundibula was found. A review of the association between the AVMs, aneurysms and infundibula, and possible etiologic factors in the relationship forms the subject of this report.

Benefits of embolization without surgery for cerebral arteriovenous malformations.

Embolization may be the primary and exclusive treatment of cerebral arteriovenous malformations. To evaluate its benefits, a group of 27 patients was studied for the incidence of hemorrhages, headaches, seizures, and neurologic deficits, both before and after Silastic sphere embolization. Questionnaires to patients and physicians were used. Embolization was found to decrease the frequency of headaches in most patients with this symptom, but had no effect on the frequency of seizures when patients in whom medical therapy was altered were excluded nor on the progression or incidence of neurologic signs and symptoms. The effect of embolization on the incidence of recurrent hemorrhages is as yet undetermined.

"Wrong-way eyes" in supratentorial hemorrhage.

A patient developed conjugate horizontal eye deviation to the side opposite a large frontal-perisylvian hemorrhage from a ruptured aneurysm. Autopsy examination confirmed the hemispheric locus of the hemorrhage and failed to disclose any lesion of the brainstem or thalamus to explain the "wrong-way" eye deviation.

Galactorrhea, oligo/amenorrhea, and hyperprolactinemia in patients with craniopharyngiomas.

We report three patients with craniopharyngiomas who had galactorrhea, oligo/amenorrhea, and abnormal sellar tomograms, clinically suggesting the presence of a prolactinoma. One patient had an intrasellar craniopharyngioma (Rathke's cleft cyst) diagosed during surgical exploration of the pituitary fossa for removal of a suspected prolactinoma, and two had suprasellar caraniopharyngiomas whose presence was suspected on the basis of computed tomography. This finding emphasizes the importance of computed tomography in the evaluation of patients with the clinical presentation of a prolactinoma. In two patients, PRL levels were elevated before surgery and remained elevated after removal of the craniopharyngioma. In the third case, an initially normal serum PRL level became elevated after removal of the tumor.

Solitary osteochondroma of the cervical spine.

Solitary osteochondroma of the cervical spine is extremely rare. We reviewed the literature on this disorder, studied a case of an osteochondroma arising from the bony margin of the foramen transversarium of the sixth cervical vertebra, and concluded that osteochondroma should be considered in the differential diagnosis of a palpable mass in the neck. Despite the benign histologic nature of osteochondromata, those located in the cervical spine in proximity to vital vascular and neurologic structures should be excised surgically.

Meningiomas of the pineal region and third ventricle.

The clinical presentation, radiological findings, and surgical management of two cases of meningioma arising from the velum interpositum without dural attachment are described. The true nature of these tumors was not suspected despite extensive preoperative diagnostic evaluation. A total removal was effected in both cases with the use of the operating microscope and a posterior fossa approach to the pineal region. A review of similar cases from the English literature is presented.

Arthrographic diagnosis of synovial chondromatosis.

A case of synovial chondromatosis without plain film calcifications is presented. The arthrographic findings and differential diagnosis are discussed.