Myeloma Presenting in the Base of the Skull.

Of 385 consecutive patients with a proven diagnosis of myeloma seen over a 15 year period, only four presented with symptoms and signs due to involvement of the skull base. This rare occurrence is in striking contrast to the frequency with which radiologic changes can be demonstrated in the bones of the calvarium during the course of most individual's disease. Response to treatment was obtained in all four, of whom one is a longterm survivor. This experience is reported emphasising the need to consider the possibility of myeloma in people with unexplained craniospinal symptoms and signs. In addition, the radiologic changes are tabulated in the hope that a pattern may emerge which will alert physicians to the presence of this rare situation.

Endocarditis-related cerebral aneurysms: radiologic changes with treatment.

PURPOSE: To document the response of mycotic aneurysms to antibiotic therapy and correlate these findings with patient outcome. METHODS: Clinical findings, CT studies, and serial cerebral angiograms of patients with endocarditis related aneurysms seen over 10 years were retrospectively reviewed. RESULTS: In 14 patients infective endocarditis was diagnosed. The patients presented with subarachnoid haemorrhage (4 patients), stroke (9 patients), and seizure (1 patient). CT findings were intracerebral hematoma (5 patients), infarcts (4 patients), subarachnoid hemorrhage (4 patients), and aneurysms (2 patients). On angiography, 10 (71%) patients had single aneurysms, and 4 (29%) patients had multiple aneurysms. Eighteen aneurysms were detected, of which 6 (33%) were centrally located, and 12 (66%) were located peripherally. The most common site was the peripheral middle cerebral artery (56%). Serial angiography during antibiotic treatment demonstrated complete resolution of 6 aneurysms (33%), with 12 aneurysms remaining after 6 weeks of treatment. Of the latter, there was no change in size in 6 aneurysms (33%), a decrease in size in 3 aneurysms (17%) and an increase in size in 3 aneurysms (17%). No new aneurysms appeared. Surgery was performed on 10 patients with residual aneurysms, 11 aneurysms being excised or clipped. After 6 weeks' treatment, there was complete recovery in 7 (50%) patients, permanent neurologic deficits in 6 patients, and death from aneurysm rebleed in 1 patient. CONCLUSION: Follow-up angiography is recommended in all patients with mycotic aneurysms to assess response to antibiotic therapy, to detect new aneurysms, and to identify those aneurysms with no response or with enlargement.

Carotid artery disease in young adults.

The angiographic and clinical findings in 17 young adults (14-39 years) with stenosis and/or occlusion of at least one of the common or internal carotid arteries were reviewed to determine the spectrum of carotid artery disease in this age group. Five aetiological groups were identified: atherosclerosis (3 patients), arteritis (4), non-inflammatory arteriopathies (6), compression by neoplasm (1), and occlusions of undetermined cause (3). Over a mean follow-up time of 19.7 months, 2 patients died (12.5%) and further cerebrovascular events occurred in 4 others (25%). We conclude that carotid angiography plays a meaningful role in providing a definitive diagnosis in young adults with carotid artery disease and thus may assist with therapy and prognosis.

The acute orbit: differentiation of orbital cellulitis from subperiosteal abscess by computerized tomography.

A series of 65 patients suffering from acute inflammatory disease of the orbit was studied by CT. Ethmoiditis was the cause in the vast majority; trauma and dental extraction played a lesser role in causation. Orbital cellulitis was diagnosed in 17 and subperiosteal abscess in the remaining 48. It was not possible to differentiate 33 pus-containing abscesses from the six with inflammatory masses (phlegmons). The satisfactory response to aggressive medical treatment in those patients with inflammatory masses that were not drained justifies a more conservative approach; surgical drainage being reserved for those with a deterioration in proptosis, ocular movements or vision. Six abscesses arose de novo, of which some were in the orbital fat rather than the subperiosteal space.

Cerebral cysticercosis with reference to the natural history of parenchymal lesions.

The cerebral parenchymal response to degeneration of cysticerci was studied in 83 consecutive patients investigated over 5 1/2 years. Virtually all came from an endemic region of South Africa and 67% were children. Occasionally, computed tomography (CT) delineated an inert shower of cysticerci. The humoral and tissue reactions resulting from larval death cause intense cerebral edema and granulomata, which manifest particularly in the pediatric age group. Local and diffuse cerebral edema has not been stressed before nor has its incidence been evaluated. The shortest interval between cysticercal degeneration and its granulomatous response to the final radiographic calcification was found to be 25 months.

Computed tomography of infratentorial masses in children.

Seventeen cases of infratentorial mass lesions (excluding abscesses) in children are reviewed. The findings after computed axial tomography (CAT) are described, as well as the changes that were revealed by plain radiographs of the skull. Ancillary investigations were performed in 11 cases, and their usefulness is assessed. The possibility of making a provisional diagnosis of the nature of the lesion based on CAT findings is discussed.

Postmeningitic hydrocephalus in infancy. Ventriculography with special reference to ventricular septa.

Postmeningitic hydrocephalus in infancy accounts for at least 30% (maybe even 40%) of all new paediatric hydrocephalics seen in the Cape Province. The causes of the marked racial preponderance are considered. Meningitis is more prone to cause a CSF pathway block at any site in infancy than later in life. On ventriculography ventricular septa in 23%, foramen of Monro obstruction in 13%, multiple CSF pathway block occasionally and intraventricular detritus causing filling defects and irregularities of the ventricular walls are the salient features. Birth trauma with intraventricular bleeding may on occasion cause similar changes.