Upward transtentorial herniation: seven cases and a literature review.

Seven cases of upward transtentorial herniation occurred. In each patient, coma with reactive, miotic pupils, asymmetrical or absent caloric responses, and decerebrate posture indicated brain-stem compression. In this setting, the development of unequal, then midposition, fixed pupils signaled midbrain failure from upward herniation. Vertebral angiography showed upward displacement of the superior cerebellar arteries. Results of autopsy confirmed the existence of grooving of the vermis by the tentorial margins and, in one case, of anterior displacement and distortion of the midbrain. In five of 45 reported cases of upward herniation, the conditions were diagnosed antemortem. Instances of cerebellar hematoma and tumor predominated. In at least seven patients, performance of ventriculography may have precipitated herniation. Clinical details were provided in only nine patients and did not separate upward herniation from brain-stem compression. Cerebellar ischemic infarct found in one of our patients is a rarely reported cause of upward herniation.

Radionuclide angiography: a sensitive diagnostic test for anterior circulation ischemia.

Radionuclide angiography, using high resolution equipment, is a sensitive noninvasive, safe, and rapid diagnostic test for ischemia of the anterior circulation of the brain. The test permits recognition of focally increased or decreased circulation immediately following the onset of a neurologic deficit. The sensitivity of the test is improved by using multiple projections of the head. The distribution of the anterior cerebral artery is best seen in the anterior projection; the lateral projection is used to resolve the superior and inferior divisions of the middle cerebral artery or to identify multiple regions of ischemia. Both projections should be used routinely.

Carotid-cavernous fistula. Demonstration of asymptomatic vascular "steal".

Abnormal distribution of cerebral vascular flow was studied in a patient who had a traumatic carotid-cavernous sinus fistula. Serial studies were performed using a method for determining relative cerebral vascular flow:99mtechnetium-diethylenetriamine pentaacetic acid (99mTc-DTPA) was injected intravenously and flow data were processed by a digital computer. Serial studies documented the occurrence of a vascular "steal" during temporary carotid occlusion; postoperative studies showed disappearance of the steal and obliteration of thiling arterial structures and capillary filling in the brain, and in demonstrating alteration in the cerebral circulation.

Benign nasal polyps causing bone destruction in the nasal cavity and paranasal sinuses.

Benign nasal polyposis, when extensive, can cause bone displacement and destruction within the nasal cavity and paranasal sinuses. Consequently it may be difficult to distinguish this entity from a malignant neoplasm.

Hemorrhage from open pelvic fracture controlled intraoperatively with balloon catheter.

In the case reported, many techniques for controlling bleeding from an open pelvic fracture were employed without success. With arteriographic identification of a precise arterial bleeding point, control of hemorrhage was accomplished by proximal hypogastric artery ligation with distal intraarterial placement of a balloon catheter.

Dynamic radionuclide scanning in the diagnosis of thrombosis of the superior sagittal sinus.

Two cases of superior sagittal sinus thrombosis were diagnosed using a new technique of dynamic radionuclide brain-imaging. With the patient's head in the posterior oblique position, and 80-lens optical camera records the appearance of radionuclides in the superior sagittal sinus. This technique is quick and noninvasive, and serial studies are easily performed. Dural sinus thrombosis is difficult to diagnose on clinical findings alone. Dynamic canning should be used to screen high risk patients, such as those having pseudotumor syndrome or clotting disorders and elderly patients having pulmonary emboli or unexplained deterioration of mental status.

Stab wounds of the brain.

Unlike the penetrating injuries to the brain caused by missiles, injuries by stabbing are largely restricted to the wound tract. Early recognition, debridement and judicious antibiotic therapy can limit or prevent complications in the management of stab wounds. Among the common sequelae of stab wounds of the brain are pneumocephalus, meningitis, intracerebral hemorrhage and direct blood vessel or nerve injury.

The value of repeat cerebral arteriography in the evaluation of trauma.

In most patients with head or neck trauma, a single angiogram is sufficient to guide therapy. For those who improve slowly or not at all, however, this is not an adequate basis for diagnosis. Angiography should be repeated after an interval of time to exclude development of a surgically correctable lesion, such as pseudoaneurysm or intracerebral or extracerebral fluid collection.

Compliance characteristics of angiographic guidewires.

Although the manufacturers' specifications may be identical, brands of widely employed straight, long-paper angiographic guidewires vary considerably in performance. Because guidewire flexibility is a key factor in performance, we investigated the characteristic compliance patterns of similar guidewires (using an apparatus of our own design) from four different manufacturers. The brands were found to differ significantly in compliance at the tip, in rate of change in compliance, and in overall length of taper.

Pattern recognition in severe displacement of the thalamostriate and internal cerebral veins: the W and infinity signs.

Severe displacement of the thalamostriate and internal cerebral veins from the midline results in an unfamiliar distortion of these vessels arteriographically. Depending on the side of the mass effect, the thalamostriate-internal cerebral vein complex will have either an infinity (infinity) or a W configuration. Because these configurations appear frequently, recognition and understanding of them aid in the interpretation of cerebral arteriograms.

Cerebral hypervascularity and early venous opacification in status epilepticus. A case report.

Cerebral hyperperfusion and early draining veins directly resulting from status epilepticus can be demonstrated angiographically. Postmortem examination of the brain excluded other possible causes of hyperemia and early venous drainage.

Kinking of the aqueduct of Sylvius in the absence of posterior fossa masses.

The kinked or "hockey stick" deformity of the aqueduct of Sylvius has long been considered pathognomonic of a mass in the posterior fossa. Five patients with kinking of the aqueduct of Sylvius are described. All had intracranial abnormalities but none had a mass in the posterior fossa.

The clinical indications for arteriography in trauma to the extremity. A review of 114 cases.

Analysis of radiographic and physical findings in 114 patients with trauma to an extremity demonstrated that when other physical findings are normal, arteriography is unnecessary. If any physical sign of peripheral vascular injury exists, such as weak or absent pulse, neurologic deficit, bruit, or expanding hematoma, arteriography is essential to define the anatomy and determine the need for surgery.

Acute, Post-Traumatic Subdural Hygroma. Natural Course with Angiographic Documentation.

Acute, post-traumatic subdural hygromas, in contrast to benign chronic subdural hygromas, may be life-threatening. Two cases are presented in which a rapidly enlarging subdural hygroma either prevented improvement over a 1-2 week period or resulted in rapid deterioration of the patient. Angiographic documentation and the natural course of this condition are revealed.