Can a post-operative brace in slight hyperextension prevent extension deficit after anterior cruciate ligament reconstruction? A prospective randomised study.

It has been our observation that post-operative anterior cruciate ligament (ACL) braces together with the post-operative bandages do not always allow the knee to reach full extension. In ten uninjured knees with known hyperextension, the knees were bandaged in the same way as after an ACL-reconstruction. The knees were then studied radiologically in a Hypex brace set at 0 degrees, -5 degrees and -10 degrees of knee extension. Not a single knee was found to be straight in the brace set at 0 degrees. At -5 degrees most of the knees were straight or in slight hyperextension. It took -10 degrees to get all knees straight or in hyperextension. In a prospective randomised study 44 patients who underwent an arthroscopic ACL-reconstruction with a bone patellar tendon bone graft were randomised to use either a brace set at -5 degrees or a straight brace (0 degrees ) for at least the first three postoperative weeks. Before and three months after surgery range of motion was determined, using a goniometer with long arms, and sagittal knee laxity was measured with a KT-2000 arthrometer at manual max. Pre- and post-operative pain was evaluated with the Visual Analogue Scale (VAS). The same examiner (blindfolded to what type of brace was used) performed all the measurements. At three months, two of the 22 patients with the brace set at -5 degrees and twelve of the 22 patients with the straight brace had a loss of full extension of 2 degrees or more ( p<0.001). No significant differences were found between the groups in terms of knee flexion, sagittal knee laxity or post-operative pain. Although extension deficit after ACL-reconstruction can be prevented also in other ways, a Hypex brace set at -5 degrees seems to be an easy way of ensuring full knee extension.

Increased frequency of aberrant CSF circulation in schizophrenic patients compared to healthy volunteers.

In a previous cisternographic study of the cerebrospinal fluid (CSF) circulation in schizophrenic patients, indications for disturbed flow dynamics were found in 10 of 30 subjects. In order to replicate and investigate the clinical and pathophysiological significance of this finding, 39 schizophrenic patients and 42 healthy subjects were examined with an improved method for measurement of CSF circulation. (99m)Tc-DTPA was injected intrathecally and the gamma cisternograms were evaluated blindly. Correlations between cisternography findings and age, duration of disease, previous hospitalizations, positive or negative symptomatology, exposure to neuroleptics, psychiatric family history, CT findings and CSF levels of protein, tryptophan and monoamine metabolites, were calculated. Seven of the patients showed abnormalities in the cisternograms with a slow or obstructed flow of CSF over the convexities (P < 0.01) whereas none of the healthy volunteers showed abnormalities. There were no correlations between disturbed CSF circulation in the patients and the clinical and biochemical parameters, thus the significance of the deviations, similar to other biological aberrations found in schizophrenic patients, is not known. Recent developments in magnetic resonance imaging offer new possibilities to further examine CSF circulation abnormalities in schizophrenia.

Does Swedish amateur boxing lead to chronic brain damage? 2. A retrospective study with CT and MRI.

It is well known that professional boxers can develop chronic traumatic encephalopathy (dementia pugilistica) due to repeated head trauma. Beside CT findings indicating cerebral atrophy, the presence of a cavum septum pellucidum has been reported to indicate encephalopathy. CT findings in amateur boxers are not as well documented. The aim of this study was to find out if morphological changes could be demonstrated among former amateur boxers using CT and MRI. Two control groups of soccer players and track and field athletes in the same age-range were used for comparison. No significant differences in the width of the ventricular system, anterior horn index, width of cortical sulci, signs of vermian atrophy, or the occurrence of a cavum septum pellucidum were found between boxers and controls. A cavum septum pellucidum was found more often in the controls than in the boxers and is probably not a sign of earlier head trauma. MRI confirm no more findings than CT in this retrospective study.

Blood as tracer for CSF circulation after subarachnoidal hemorrhage.

The amount and distribution of blood in the cerebrospinal fluid following subarachnoid hemorrhage can be monitored with CT. An investigation of 110 patients was performed retrospectively in 100 patients with a total of 132 CT examinations, and prospectively in 10 patients with 40 CT examinations. During the days following the hemorrhage, the blood was redistributed within the subarachnoid space and eventually reabsorbed. The blood in the basal cisterns was cleared first, whereas the amount of blood in the cortical sulci appeared to increase after a few days, later to be cleared. It is concluded that the redistribution of the blood reflects the circulation of the cerebrospinal fluid, and that the erythrocytes thus act as tracers of this circulation. The amount of blood within the ventricular system was correlated to the size of the ventricles; patients with large amounts of blood within the subarachnoid space had hydrocephalus more often than other patients.

Cerebral blood flow and metabolism during adenosine-induced hypotension in patients undergoing cerebral aneurysm surgery.

The effects of adenosine-induced hypotension on cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and cerebral lactate production, together with systemic haemodynamics, were studied in 10 patients undergoing cerebral aneurysm surgery in neurolept anaesthesia with controlled hyperventilation. CBF changes were determined in six of the patients with a retrograde thermodilution technique in the jugular vein. Hypotension was induced with a continuous infusion of adenosine in the superior vena cava. The dose range was 0.06-0.35 mg/kg/min, and this caused a 42% reduction in mean arterial blood pressure (MABP) from 79 +/- 4 to 46 +/- 1 mmHg (10.5 +/- 0.5 to 6.1 +/- 0.1 kPa) through a profound reduction in systemic vascular resistance (SVR), which amounted to 61%. No significant change occurred in CBF. Whole body AV-difference of oxygen was decreased by 37%, and cerebral AV-difference by 28%, corresponding to reductions in whole body oxygen uptake and CMRO2 of 16 and 17%, respectively. Cerebral AV-difference of lactate did not change. In the posthypotensive period MABP was increased by 10%, together with a minor increase in CBF (15%). It is concluded, that adenosine-induced hypotension at MABP levels between 40-50 mmHg (5.3-6.7 kPa) does not affect cerebral oxygenation unfavourably, and may even offer a protective effect by reducing cerebral oxygen demand. The slight CBF increase in the posthypotensive period was probably secondary to an increase in MABP together with a blunted autoregulation, but in no case was this effect considered to be harmful for the patient.

Orbital phlebography for differentiation between multiple sclerosis and venous vasculitis in subacute blindness.

Thirteen consecutive patients with subacute unilateral loss of vision and periorbital pain but without pathology of the fundus or increased erythrocyte sedimentation rate, were investigated with visual evoked response, electrophoresis of serum and cerebrospinal fluid, and orbital phlebography. Seven of these patients were found to suffer from multiple sclerosis. The remaining 6 were considered to have venous vasculitis. There was a spontaneous recovery from visual impairment in all patients with multiple sclerosis, but not in patients with venous vasculitis. Of the latter patients, only two, who were treated with steroids within the first four days after onset of symptoms, regained vision. It appears that orbital phlebography is the diagnostic procedure of choice for proper management of patients with subacute loss of vision.

The amount of blood in CSF and degree of hydrocephalus studied with CT as compared to clinical condition and concentrations of various substances in human CSF after subarachnoid haemorrhage.

Thirty-nine (39) patients with subarachnoid haemorrhage (SAH) were studied with computed tomography (CT). The amount of blood in the cerebrospinal fluid (CSF) and the degree of hydrocephalus were evaluated. These two parameters were correlated with the clinical condition on admission and at discharge and against CSF concentration of a series of CSF substances. These included the major monoamine metabolites homovanillic acid (HVA), 5-hydroxyindole-acetic acid (5-HIAA) and 3-methoxy-4-hydroxyphenylethyleneglycol (MOPEG) and in addition the concentrations of hypoxanthine, aspartate and somatomedins. The amount of blood and the degree of hydrocephalus on admission did not seem to influence the concentration of these substances over time. It was found that patients with large amounts of blood in the CSF had a worse clinical outcome (p less than 0.05) compared to patients with no or moderate amount of blood. In addition, patients with enlargement of the temporal horns showed a worse clinical condition on admission (p less than 0.01) than did patients without such enlargement. Despite a significant (p less than 0.01) vasoconstriction there was no correlation between vascular calibre and concentration of the substances in the CSF. It is speculated whether or not the increased levels of these substances were the result of cell lysis per se, a disturbance of the CSF circulation or to the toxic effect of blood resulting in deranged metabolism in both the CSF and brain tissue after SAH.

Computed tomography of the brain in cases with venous vasculitis compared with an age-matched reference group.

Patients with a particular, steroid-sensitive headache and often characteristic pathology at orbital phlebography, have been suggested to suffer from venous vasculitis. Fifty such patients were examined with computed tomography (CT) of the brain. The findings were compared with those of an age-matched reference group selected at random to represent normal subjects. The CT examinations were analyzed with respect to size of lateral ventricles and signs of atrophy. In both groups, there was a significant increase of atrophy with age. There was also a significantly higher degree of atrophy in the patient group as compared with the reference group. The findings indicate that the supposedly underlying venous vasculitis is related to early aging and atrophy of the brain.

Chronic paroxysmal hemicrania: orbital phlebography and steroid treatment. A case report.

A 62-year-old man with ankylosing spondylitis and with a 3-year history of chronic paroxysmal hemicrania is presented. Because of his ankylosing spondylitis naproxen was prescribed; this decreased the attacks of headache to about 50%. However, treatment with indomethacin and steroids eliminated the attacks completely, the former drug in 24 h but only when the drug was taken; the latter drug was completely effective after a week but with an effect that lasted half a year after the medication was stopped. Orbital phlebography showed changes similar to those previously observed in patients with Tolosa-Hunt syndrome and cluster headache. Venous vasculitis thus seems to be associated with all three disorders and may be a factor of etiologic significance.

Orbital phlebography in patients with cluster headache.

Thirteen patients with cluster headache in an active stage were investigated with orbital phlebography. About 60% of the patients showed pathologic changes on the phlebograms, such as changes in the appearance of the superior ophthalmic vein. Five patients had pathologic changes on both sides and three patients on one side only. All patients with unilateral pathologic findings on orbital phlebography had the attacks on the same side. The phlebographic findings in these patients with cluster headache were very similar to those of patients with the Tolosa-Hunt syndrome. There is also some similarity in the symptoms in the two disorders. It has previously been suggested that the Tolosa-Hunt syndrome is caused by venous vasculitis, and the present findings to some extent support the idea that cluster headache may have the same etiology.

Long-term results of stereotactic radiosurgery to the pituitary gland in Cushing's disease.

Gamma radiation from 60Co delivered with stereotactic technique was given to the pituitary gland in 35 patients, aged 18-65 years, with Cushing's disease. The doses were 70-100 Gy in each single irradiation. The size of the sella turcica was normal in the majority of the patients. The observation time was 3-9 years in 29 patients. Out of them, 14 (48%) obtained clinical remission and normal urinary cortisol after one irradiation. Eight achieved remission after two to four irradiations. In total, 22 out of 29 patients (76%) obtained remission. In 12 of them remission was obtained in 1 year and in another 10 within 3 years. No recurrences were observed. Improvement was seen in 2 patients after one and three irradiations. Bilateral adrenalectomy was performed in 5 patients owing to unsatisfactory effect of irradiation. Pituitary insufficiency with gonadotropin, thyrotropin or corticotropin failure was demonstrated in 12 of 22 patients in remission. This occurred 4 months to 7 years after the first irradiation. Another 6 patients were followed less than 3 years after the first irradiation. Two obtained remission after the first treatment, whereas the other 4 improved. Stereotactic pituitary irradiation is suggested as a non-invasive therapeutic alternative in Cushing's disease for example in patients with considerable surgical risk or as a supplement to pituitary microsurgery.

Women with prolactinoma--effect of pregnancy and lactation on serum prolactin and on tumour growth.

Thirty-five women with prolactinoma have been investigated during 41 pregnancies and 35 lactation periods. Nine of the women had a macroadenoma; 4 of them underwent transsphenoidal microsurgery and one was treated with external pituitary irradiation before pregnancy. All nine were given bromocriptine to induce ovulation. Four women with a microadenoma became pregnant without medical treatment, one shortly after pituitary microsurgery. The other 22 women were treated with bromocriptine only for varying periods before conception. Tumour complications developed in 7 women (20%); 3 had signs of optical nerve compression and 4 showed increased sella volume after pregnancy. All women with tumour complications had been treated with bromocriptine for less than 12 months before conception. Serum prolactin (Prl) was measured every four weeks during pregnancy and after cessation of lactation. In contrast to normal pregnancy, the mean serum Prl did not increase during the second and third trimester of pregnancy in women with pretreatment serum Prl levels above 60 micrograms/l. The lactation period did not have any harmful influence on tumour development. It is concluded that neither pretreatment serum Prl nor radiological changes of the sella turcica can predict tumour development during pregnancy. Treatment with bromocriptine for more than 12 months before conception seems to reduce the risk of tumour progress.

A new etiology for visual impairment and chronic headache. The Tolosa-Hunt syndrome may be only one manifestation of venous vasculitis.

The Tolosa-Hunt syndrome is characterized by recurrent periods of painful ophthalmoplegia, dramatically ameliorated by steroid treatment. In half of the cases orbital phlebography shows characteristic changes. Ninety-six patients with orbital pain characteristic of the Tolosa-Hunt syndrome were submitted to orbital phlebography regardless of the existence of other symptoms. A pathologic phlebogram with changes typical of the Tolosa-Hunt syndrome was found in 50 patients. In 17 of these 50 patients the symptoms consisted of orbital pain only and no ophthalmoplegia. Twenty patients had pain and ipsilateral decrease of vision but no ophthalmoplegia, and 13 had painful ophthalmoplegia. Of 41 patients treated with steroid medication 39 responded dramatically with regard to the pain. Earlier findings indicate that the phlebographic changes are due to venous vasculitis, which thus may cause irreversible visual impairment but also chronic headache without ophthalmoplegia. It is concluded that the Tolosa-Hunt syndrome may be only one manifestation of a not uncommon disease.

Radionuclide cisternography and computed tomography in 30 healthy volunteers.

Radiological assessments of patients with symptoms of impaired cerebrospinal fluid (CSF) circulation are usually based on observations of anatomical and functional alterations using computed tomography (CT) and radionuclide cisternography (RC). In order to define criteria of normality for these two techniques, 30 healthy volunteers have been studied. In the studies of CSF flow the radiopharmaceutical 99mTc-DTPA was used and single photon emission computed tomography (SPECT) was performed as a complement to planar scintigraphy. In 16 of the 30 volunteers the pattern of CSF flow was normal according to conventional criteria. In these subjects the radioactivity was symmetrically located over the parietal cortex 24 h after the injection and no intraventricular activity could be recorded. In 11 (41%) of the subjects, radioactivity could be observed in the lateral ventricles 6 h after injection. One of these subjects had a reflux of radioactivity into the lateral ventricles. The intraventricular radioactivity persisted for at least 24 h. This subject also had signs of obstruction of CSF flow over the convexities. Asymmetric distribution of radioactivity within the CSF spaces was observed in the images obtained after 6 but not 24 h in two cases. One of those also demonstrated transient intraventricular radioactivity. The results of the computed tomography were interpreted to be normal in 19 (63%) of the 30 volunteers. One subject had an asymmetric ventricular system. The CT scans of six subjects (20%) differed considerably from the others as they displayed wide cortical or vermian sulci at the borderline of normal variations. The case with the pathological RC belonged to the group of subjects who had wide sulci.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional cerebral blood flow determined with single photon emission computed tomography and positron emission tomography. A comparative study.

The regional uptake of 99Tcm-labelled HMPAO has been measured with single photon emission computed tomography (SPECT). The potential value of 99Tcm-HMPAO as a flow tracer was evaluated. The uptake of 99Tcm-HMPAO as a function of time indicated that the tracer was trapped in the brain. The uptake images were compared with results from quantitative regional cerebral blood flow (rCBF) measurements using positron emission tomography (PET) and with 11C-fluoromethane used as a tracer. There was a strong correlation between the uptake of 99Tcm-HMPAO and rCBF. The conclusion was that the uptake of 99Tcm-HMPAO was dependent on rCBF.

Method for quantification of low flow velocities by magnetic resonance phase imaging.

The aim of this study was to compare the influence of flow in the velocity range 0 to 25 mm/s on modulus, phase, real and imaginary images obtained with a standard magnetic resonance scanner (Siemens Magnetom, 0.5 T), and to develop a simple method for determination of flow velocities in vivo from this information. Using a flow phantom, the flow dependent magnetic resonance imaging (MRI) signal has been studied as a function of flow perpendicular to the image slice with non-doped water (simulating moving cerebrospinal fluid) as well as with water doped with Mn2+ (simulating moving blood) for each of the four mentioned image types. The results show a marked flow dependence on all types of images studied. The variation of the signal with flow in the modulus images is relaxation-time dependent in the studied velocity range and it is non-monotone for non-doped water. In the phase images, however, the variations are monotone and not dependent on relaxation times. In modulus images the curve shape is relatively independent on flow direction, while phase images are clearly dependent on flow direction in the studied velocity range. The signal versus velocity curves for the real and imaginary images show resemblance to those for the modulus and the phase images, respectively. It is concluded that the phase information can be used to generate a signal versus velocity calibration curve, which can be used to quantify low flow velocities in vivo.

Cerebrospinal fluid flow studied with gated magnetic resonance imaging during the various parts of the cardiac cycle.

The pulsatile movement of cerebrospinal fluid (CSF) through the Sylvian aqueduct has been studied in two normal volunteers. A standard magnetic resonance scanner was used as well as a routine spin echo sequence. Series of ECG-gated axial images were obtained perpendicular to the long axis of the Sylvian aqueduct. Previously it has been demonstrated by flow phantom experiments that the phase information can be used to obtain a linear relation between phase and flow velocity. By multiplying the CSF flow velocity by the cross-sectional area of the aqueduct of Sylvius obtained in each image, the CSF flow variation during the cardiac cycle could be demonstrated and measured.

Cardiac gated MR imaging of cerebrospinal fluid flow.

This is a preliminary investigation of the cerebrospinal fluid (CSF) spaces using cardiac gated magnetic resonance imaging. A variation of intensity of the signal from the cerebral aqueduct is demonstrated during the cardiac cycle. The pattern of this variation suggests pulsatile CSF flow. Calculations that have been verified by phantom measurements show that CSF flow rates less than 1 mm/s may be detectable. Magnetic resonance may therefore offer a new method for the demonstration and measurement of CSF flow.

DNA and S-phase representation in human growth hormone producing pituitary adenomas.

The DNA contents of 33 pituitary adenomas from patients with acromegaly were analysed with flow-cytofluorometry. Degrees of ploidy and the proliferation rate, expressed as percentage of cells in S-phase, were determined. The aim was to compare these morphological and functional tumour properties with clinical and laboratory parameters to establish a possible relation and to further elucidate the characteristics of these tumours. In 15 tumours (45%) diploid DNA pattern were found, while 18 (55%) showed varying degrees of aneuploidy. The frequency of cells in S-phase showed wide variations and were equally distributed in diploid and aneuploid tumours. Duration of symptoms, age at diagnosis, preoperative growth hormone (GH)- and prolactin (Prl)-levels, tumour size and grade of invasive tumour growth as determined by radiological estimations, did not correlate to ploidy or grade of proliferation. The lack of correlation between DNA pattern and proliferation rate in relation to clinical, laboratory and radiological parameters in tumours causing acromegaly contrasts to the documented relation between the degree of ploidy, cells in proliferation and grade of malignancy reported in tumours of other sites. The 55% aneuploid GH producing tumours indicate a certain malignant transformation. The high frequency of cells in S-phase in several GH secreting tumours completes the malignant morphological and functional cell properties. The benign character of tumours causing acromegaly is therefore in contrast to these findings. The lack of clinical significance of the DNA pattern and the frequency of cells in proliferation in GH producing tumours and the benign character despite malignant cell properties in most of these tumours are difficult to explain.(ABSTRACT TRUNCATED AT 250 WORDS)

A special cut-off gamma camera for high-resolution SPECT of the head.

A modern system for single photon emission computerized tomography has been modified in order to optimize examinations of the head. By cutting off part of the detector housing and collimators at one edge, it is possible to rotate the camera close to the skull while still covering the entire brain and the skull base. The minimum radius of revolution used in 32 patients was thereby reduced from about 20 cm to 12.7 +/- 0.8 cm. This, combined with an adjustment of the 64 X 64 matrix to a 26- by 26-cm field of view, resulted in an improvement of the spatial resolution from about 19 mm to 12.6 +/- 0.3 mm with a low-energy, all-purpose collimator, and to 10.4 +/- 0.3 mm (FWHM) with a low-energy, high-resolution collimator. The improved spatial resolution offers several clinical advantages in studies of the brain, the cerebrospinal fluid space, and the skull base.