Acute osteomyelitis as a complication of varicella.

Varicella is a common viral infection in childhood, and acute osteomyelitis is one of the rare but serious complications. We report two cases of osteomyelitis as a complication of varicella. The possibilities and limitations of the different imaging modalities are discussed, as well as imaging findings during the course of this condition.

Conventional and diffusion-weighted MRI in the evaluation of methanol poisoning.

Cerebral lesions were studied in 2 methanol-poisoned patients using conventional magnetic resonance imaging (MRI). In 1 patient, diffusion-weighted MRI (DWI) was also performed. In this patient, conventional MRI showed symmetrical, bilateral increased signal in the lentiform nuclei, involving predominantly putamina, but also extending into the corona radiata, centrum semiovale and subcortical white matter. DWI showed decreased diffusion, which most probably reflects cytotoxic edema. In the other patient, fluid attenuated-inversion recovery (FLAIR) and T2-weighted images showed hyperintensity in the putamina, characteristic of post-necrotic changes.

Accuracy of CT scan measurements of the medial temporal lobe in routine dementia diagnostics.

BACKGROUND: Atrophy of the medial part of the temporal lobe is seen in Alzheimer's disease (AD). We studied the usefulness of CT scan measurements of the medial temporal lobe (MTL) in elderly with suspected dementia. METHODS: MTL measurements were done with callipers by three raters, blinded to the diagnosis and to each other, on scans from 110 subjects with suspected dementia from a memory clinic in Oslo, Norway and 36 participants included in the OPTIMA study, Oxford, England. RESULTS: The correlation between the MTL and the Mini-Mental State Examination (MMSE) was very low, and there was a marked overlap between Alzheimer and cognitively unimpaired subjects. The inter-rater reliability was lower on the Norwegian than on the OPTIMA scans (R = 0.48 vs R = 0.68), but this was partly explained by larger MTL readings (4.5 mm after adjustment for age, gender and MMSE sumscore) on the OPTIMA scans as the reliability was confounded by MTL width and was higher at larger MTLs. A wider scan width (3 mm vs 2 mm in the OPTIMA scans) can also contribute to differences in reliability. CONCLUSIONS: The published threshold values regarding the CT scan MTL measurements for the diagnosis of AD may be invalid when applied by other radiology departments without a local standardisation and validation.

Vertex epidural hematoma - neuroradiological findings and management.

Epidural hematomas occurring at the vertex are uncommon, and they can be difficult to diagnose by axial CT. We report a case of acute traumatic vertex epidural hematoma, which resolved spontaneously with time. We stress the importance of MR investigations in this diagnostic challenge.

Post-traumatic cerebral infarction. Neuroimaging findings, etiology and outcome.

PURPOSE: To assess the radiological characteristics of post-traumatic cerebral infarctions (PTCIs), the etiology and site of infarction, and to provide neuroimaging indicators of a poor clinical outcome. MATERIAL AND METHODS: A retrospective study of 16 patients with the neuroimaging-based diagnosis of PTCI was carried out. All CT, MR examinations, cerebral angiograms and medical records of the patients were reviewed. RESULTS: Infarcts were diagnosed in the territory of the posterior cerebral artery in 9 patients, in the middle cerebral artery in 5, in the anterior cerebral artery in 3, lenticulostriate-thalamoperforating in 2, vertebrobasilar in 3, and cortical infarcts in 2 patients. Neuroimaging studies suggested focal mass effect and/or acquired intracranial herniations as the cause of infarction in 13/16 patients (81.2%). In 3/16 patients (18.8%), PTCI was due to vascular injury of which 2 were angiographically documented (carotid artery dissection). Eight of the 16 patients in this study died or were left in a persistent vegetative state. Patients with associated subdural hematoma, brain swelling/edema and traumatic subarachnoid hemorrhage (tSAH) exhibited the worst outcome. CONCLUSION: Gross mechanical shift of the brain and herniation across the falx and/or tentorium accounted for infarction in a majority of cases in our study. The overall death rate was 43.8% and this result suggests that PTCI is an indication of a poor clinical outcome, especially among patients with associated subdural hematoma, brain swelling/edema and tSAH.

Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests.

The present study seeks to elucidate the relationship between unawareness of illness in schizophrenia and frontal lobe dysfunction, in addition to investigating the relationship between lack of insight and sociodemographic and clinical variables. Twenty-one medicated schizophrenic patients, recruited from in- and out-patient wards at Ullevâl Hospital, underwent the Scale to Assess Unawareness of Mental Disorder (SUMD), neuropsychological testing, psychiatric symptom ratings and neuroimaging procedures (CT). Also, 21 matched normal controls were neuropsychologically tested. CT data were assessed blindly by two experienced neuroradiologists, according to the degree of ventricular enlargement and/or sulcal widening, and an assessment of localisation of atrophy was made. Unawareness of illness was correlated with neuropsychological measures related to executive functioning, but not with other neuropsychological measures. Five patients showed slight frontal atrophy, while two showed moderate frontal atrophy. The remaining 13 patients did not show signs of frontal lobe atrophy. Frontal lobe atrophy documented by structural brain measures was associated with poor insight in schizophrenia. Furthermore, Anergia (BPRS), GAF score and 'undifferentiated' sub-diagnosis correlated with SUMD scores. Unawareness of illness in schizophrenia may be related to frontal lobe deficit. Also, awareness of illness may not be related to general psychopathology, but rather to specific aspects.

Three dimensional CT evaluation of occipito-atlanto-axial dislocation in rheumatoid arthritis.

Involvement of the upper cervical spine, with possible instability and dislocation of the atlanto-axial-cervico-occipital joints in patients with rheumatoid arthritis (RA), is routinely monitored with conventional radiographs. As disease progresses severe interpretation problems occur, especially when looking for cranial migration of the odontoid process. The aim of the present study was to evaluate whether three dimensional CT examination should be considered for such monitoring. After clinical and biochemical examination of 20 consecutive patients, diagnostic information about cranial migration of the odontoid process was obtained by conventional radiograms and by three dimensional CT examination. When using conventional radiographs the odontoid process and the its relation to the skull base could be outlined in 8 of the 20 patients. whereas all bony structures could be well demonstrated on the CT examination and the degree of cranial migration into the foramen magnum could be quantified. Three dimensional CT should be considered as a reliable examination for monitoring RA patients with involvement of the upper cervical spine and a possible cranial migration of the odontoid process.

Influence of fibrinolytic factors on scar formation after lumbar discectomy. A magnetic resonance imaging follow-up study with clinical correlation performed 7 years after surgery.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To assess the amount of scar tissue by viewing magnetic resonance images, and to evaluate the correlation between the amount of scar tissue and clinical outcome, surgical technique, and fibrinolytic factors. SUMMARY OF BACKGROUND DATA: The influence of fibrinolytic factors on magnetic resonance images has not been investigated previously. The relation between clinical outcome and findings on magnetic resonance imaging remains uncertain. METHODS: Magnetic resonance imaging at 0.5 Tesla was performed to produce sagittal and axial spin-echo T1-weighted images before and after contrast enhancement on 78 patients 7 years after traditional lumbar discectomy with partial or full laminectomy. Before surgery all patients had been tested for fibrinolytic factors. RESULTS: The overall clinical success rate of the surgery was 73%. No evidence of scar formation was seen in 19 patients, a small amount was seen in 36 patients, a moderate amount in 17 patients, and a large amount was observed in 6 patients. Ten patients who had undergone surgery at two disc levels and 18 who had been treated with full laminectomy exhibited more scar tissue than those patients who had undergone surgery on a single level (P = 0.033) and those who had undergone a partial laminectomy, respectively (P = 0.017). The amount of scar formation also was associated with a poor outcome (P = 0.017) and with low preoperative values of tissue plasminogen activator antigen (P = 0.003) and tissue plasminogen activity (P = 0.048) in samples collected after venous occlusion. The intensity of contrast enhancement, however, was not influenced by these or any other parameters. CONCLUSION: The amount of scar formation after lumbar discectomy seems to be related to the clinical outcome, the size of the surgical exposure, and some fibrinolytic factors.

[Osteomyelitis as a complication of varicella]. / Osteomyelitt som komplikasjon ved varicella.

Osteomyelitis is a rare complication after varicella. It should, however, be considered in any child who develops pain in a limb during or after a varicella infection. An 18 month old boy with a five day history of varicella infection was hospitalized. Movement of his right arm made him cry intensively. Blood cultures showed growth of group A beta haemolytic streptococcus. The day after admission to hospital the bone scintigrams showed increased activity in the right humeral diaphysis consistent with osteomyelitis, and penicillin therapy was started. On radiograms of the right humerus performed on the second day, no pathological changes could be shown. Radiograms after ten days showed irregular osteolytic lesions in the upper part of the humeral diaphysis. Clinically, the boy improved rapidly and could be dismissed from hospital after 17 days. Follow-up radiograms showed slowly normalized conditions, and five months after the start of symptoms, no pathological changes should be demonstrated.

[Krukenberg tumor. A seldom considered condition?]. / Krukenbergs tumor. En lite påaktet tilstand?

In 1896, Krukenberg described what he presumed was a new type of primary ovarian neoplasm. The true metastatic nature of this lesion was established six years later. Some 10% of all ovarian malignant lesions are regarded as metastatic. Of these, approximately 50% are Krukenberg tumours. The tumour is well defined histologically and is usually secondary to a tumour in the gastrointestinal tract. We describe the case of a 48 year old woman with gastric cancer who, three years after diagnosis and subsequent total gastrectomy, was referred to us for observation with peritoneal involvement. We stress the importance of careful clinical and radiological follow-up of female patients with gastrointestinal cancer.

[Computer tomography of pathological neck lesions]. / Computertomografi av patologiske tilstander på halsen.

The introduction of high resolution computed tomography (CT) has significantly improved the quality of imaging of neck masses. Incremental dynamic scanning immediately after a quick bolus injection of contrast medium is essential in a majority of patients in order to obtain an optimum of information. This is especially true in the identification, mapping and staging of malignant lesions, which is the main indication for the examination. CT is also very sensitive, and yields detailed information about the location and extent of cystic and other benign lesions. Owing to the low attenuation of fat, the examination is very specific with respect to lipomas. CT has low specificity in the differentiation between benign and malignant lesions, and between cysts and solid tumours of the thyroid gland. In thyroid and parathyroid imaging other modalities such as ultrasound and scintigraphy are often more specific.

[Abnormality as differential diagnosis in atlas fracture]. / Anomali som differensialdiagnose ved atlasfraktur.

In some patients, suspected fractures of the cranial part of the cervical spine are difficult to diagnose properly without the use of computed tomography or MT. In addition to imaging and positioning problems, the possibility of anomalies of the atlas vertebra may complicate the diagnostic considerations. Proper knowledge of such anomalies may facilitate the diagnostic procedures. The diagnostic problems are discussed, and are illustrated through two patients recently examined in our department.

Combined endovascular and surgical treatment in vertebral arteriovenous fistula. A case report.

A 7-year-old girl with a right-sided congenital arteriovenous fistula in the neck was admitted with signs of cardial incompensation. Her fistula was fed from the right vertebral artery in antegrade as well as retrograde directions. A steal from the intracranial arteries was established. In addition, smaller feeding arteries from the neck were found. She was operated on with ligation of the right vertebral artery proximal to the fistula but the attempted ligation of the artery cranially to the fistula was unsuccessful. She was therefore embolized by the formation of a plug of platinum fiber coils in the upper right vertebral artery. Catheterization was performed from the left vertebral artery via the basilar artery. Persisting minor feeders to the fistula from cervical arteries were embolized in a second session. Finally, surgical extirpation of the fistula was performed together with the operative ligation of a crossover feeding artery from the left vertebral artery. Her heart size, heart rate and blood pressure were successively normalized.

[Embolization of cerebral aneurysms. A new therapeutic possibility]. / Embolisering av cerebrale aneurismer. Et nytt behandlingstilbud.

Treatment of cerebral aneurysms with Guglielmi Detachable Coils (GDC) was performed for the first time in Scandinavia in 1992. The experience at Ullevål University Clinic from 1994 to 1996 comprises 27 surgically inoperable aneurysms. Successful embolization was performed in 20 patients. No complications were seen during the procedure. However, renewed bleeding with fatal outcome occurred in one patient. In accordance with other colleagues we consider this treatment to be unsuitable for wide neck aneurysms (> 5 mm). For this reason seven patients were not treated. We conclude that GDC embolization seems to be an effective therapy for selected inoperable aneurysms. In the near future the method will probably be used to treat some of the surgically operable aneurysms as well.

Anatomic variations and pathologic conditions as risk factors of complications in percutaneous lumbar nucleotomy.

SUMMARY: This study was carried out to assess anatomic variations and pathologic changes associated with a potentially increased risk of complications during percutaneous nucleotomy. The MRI and CT examinations of 88 patients were reviewed with regard to the positional relationship between the trajectory to the disc and the bowel and iliac vessels respectively at the L4-L5 and L5-S1 levels. Pathologic conditions involving the anterior part of the annulus were assessed both by MRI and by CT-discography of 97 discs. The shortest distance from the needle course to the bowels was 29 mm. At ten other disc levels this distance was less than 40 mm. The position of the bowels is influenced by the size of the patient, the size and course of the psoas muscles and the amount of retroperitoneal fat. The bowels are at greaten distance from the trajectory at the L5-S1 than at the L4-L5 level. The risk of bowel puncture seems to be minimal. The iliac vessels were positioned behind the midportion of the disc in three patients. There was greater variation and a shorter distance to the trajectory at the L5-S1 than at the L4-L5 level. Anterior disc hernias, and particularly severe annular degeneration involving the anterior part of the annulus are frequently seen. These conditions include a weakening of the annulus and may increase the risk of anterior perforation during nucleotomy.

Depressed mood and intra-hemispheric location of lesion in right hemisphere stroke patients.

42 stroke patients with verified right hemisphere lesions were studied. Depressed mood was measured by means of a global rating scale, and an inventory administered as a structured interview. As measured by the global ratings and one of the inventory subscales, patients with deep, retrorolandic lesions showed significantly more depressed mood than other patients. The findings are discussed in the light of current relevant research, and implications for management of depressed mood in stroke patients are suggested.