A more systemic management of subdural hematoma with the aid of CT scan.

Computerized tomography (CT) allows an easy evaluation of the current methods of treatment of chronic subdural hematoma. In a prospective study of 20 consecutive patients, burr-hole evacuation or conservative management monitored by CT proved effective invariably. All patients had returned to normal when discharged from hospital.

Routine preoperative chest radiography in non-cardiopulmonary surgery.

Preoperative radiography was performed on 667 consecutive patients undergoing elective non-cardiopulmonary surgery in a large hospital in Wales. Of all significant findings reported 54% were due to cardiomegaly and 19% to chronic respiratory disease, and no appreciable abnormality was found in any patient under 30. Out of a subsample of 152 examined prospectively, 38% had received a chest radiograph within the last year, and the maximum marrow dose had been exceeded in 12-5%. It is concluded that the procedure, as presently practised, is not only being considerably overused but is also exposing many recipients to the potentially harmful effects of over-irradiation. The findings provide further evidence in support of the Royal College of Radiologists' proposal that a national multicentre study of diagnostic radiology should be set up with some urgency.

Evaluation of radiography and isotopic scintigraphy for detecting skeletal metastases in breast cancer.

Experience with technetium-phosphate compounds for skeletal scintigraphy in patients with breast cancer was analysed. When tumours were 5 cm or less in diameter (T1-2N0-1M0) metastases were demonstrated by radiographs in 1-7% (2/114). However, when radiography did not demonstrate metastases, lesions were found by scintigraphy in 41-3% (19/46). When lesions demonstrated by scintigraphy at the same site as abnormalities regarded as "benign" by radiography were excluded, 23% (11/46) had scintigraphs strongly suggestive of metastases. It is proposed that routine radiographic skeletal survey for patients presenting with breast cancer be abandoned, and replaced by skeletal scintigraphy, chest radiography, and specific localised radiographs of lesions demonstrated by scintigraphy. It is suggested that with this policy the development of expertise in interpreting scintigraphs will be accelerated, the cost of pre-treatment assessment will be reduced, and clinical management rationalised.

Isotope encephalography in the management of acute herpesvirus encephalitis.

Two patients with Herpesvirus hominis (herpes simplex) encephalitis were investigated by serial isotope encephalograms using technetium-99m pertechnetate. In the first case the diagnosis was made by brain biopsy, and by successful tissue culture, and was confirmed by a significant rise in antibody titre, but in the second the laboratory evidence was exclusively serological. Necrotizing encephalitis was presumed in both cases because the illness was grave and focal signs developed in conjunction with radiological and electroencephalographic evidence of circumscribed lesions of the hemisphere. The emergence of new lesions in the brain scan at a time of clinical remission was found to be a warning of impending relapse. Such lesions had to be distinguished from areas of increasing uptake of isotope due only to local change in vascular permeability. Decay of EEG activity together with clinical signs of focal abnormality over an area of isotope concentration indicated a necrotizing lesion. Cytosine arabinoside (cytarabine), an alternative to idoxuridine as an antiviral drug, was used in both cases. A third patient, suspected in life of having a degenerative encephalopathy, was found at necropsy to have necrotizing encephalitis. Herpes infection though probable was not confirmed. The most severe lesions were in the frontal and temporal lobes, which had shown increased uptake of technetium in the encephalogram performed six weeks before her death.