Neuropsychologic functioning of human immunodeficiency virus-infected children with hemophilia.

Efforts to detect subtle but objective neuropsychologic deficits could clarify the early involvement of the central nervous system and the progression of human immunodeficiency virus (HIV) infection in older children and young adolescents. Baseline examinations of 63 children and adolescents with hemophilia were conducted by examiners unaware of HIV status or staging or of our study's major hypotheses. They measured six domains of neuropsychologic functioning (motor, language, memory, attention, visual processing, and problem solving), and no differences between groups of similar age, race, and socioeconomic status defined by HIV seropositivity (n = 25) and HIV seronegativity (n = 38) were revealed. A high incidence of subtle neuropsychologic deficits relative to (1) age norms and (2) individual cognitive potential was found on measures of motor performance, attention, and speeded visual processing within both infected and uninfected groups. On the basis of these baseline data, it seems premature to attribute early, subtle neuropsychologic deficits in seropositive children with hemophilia to the central nervous system effects of HIV infection.

Cerebrospinal fluid analysis in human immunodeficiency virus infection.

Cerebrospinal fluid (CSF) analytes were evaluated in 59 human immunodeficiency virus (HIV+) individuals to assess neurological involvement. Glucose, total protein, cell counts, p24 antigen, CSF: serum albumin/IgG ratios, and oligoclonal bands were measured. Eighty percent of samples showed abnormalities in one or more analyte. In some patients samples, these abnormalities could mimic those of secondary opportunistic infection when none was present. The presence of oligoclonal banding in CSF (31 percent) and disturbances in CSF: serum albumin/IgG ratio (30 percent) were related to decreases in serum CD4+ lymphocytes. Disturbances in CSF: Serum albumin/IgG ratio were also related to severity of non-neurological HIV disease staging. Cerebrospinal fluid oligoclonal bands were distinct from that found in serum in the same subjects. Since immune complexes between immunoglobulins and enzymes are observed in these same patients, these oligoclonal bands may result in artifactually elevated enzyme results secondary to decreased clearance leading to erroneous clinical decisions. There was no significant relationship between any abnormalities and the presence of neurologic disease as established by a wide variety of other studies. It is important to recognize the limits of CSF interpretation in this patient group.

Peripheral neuropathy in a cohort of human immunodeficiency virus-infected patients. Incidence and relationship to other nervous system dysfunction.

A cohort of 94 patients infected with human immunodeficiency virus was evaluated clinically and electrophysiologically for the presence of peripheral neuropathy, and the results were compared with evaluations of central nervous system function. Thirty-two (34%) had some degree of peripheral neuropathy; 18 (19%) (six [12%] of the 49 asymptomatic patients, five [45%] of the 11 patients with acquired immunodeficiency syndrome [AIDS], and seven [21%] of the 34 patients with AIDS-related complex) had neuropathy on clinical examination; and 21 (23%) (eight [16%] asymptomatic, four [36%] AIDS, and nine [26%] AIDS-related complex) had neuropathy on electrophysiologic evaluation. There was a significant correlation between the presence of neuropathy and evidence of central nervous system dysfunction.

Gadolinium-DTPA enhancement of lung radiation fibrosis.

Gadolinium-diethylenetriamine pentaacetic acid (DTPA) enhancement of radiation-induced apical pulmonary fibrosis was observed in two patients previously treated for breast cancer. In one case the fibrosis was biopsied twice, with no change in its CT appearance over 3 years. Gadolinium-DTPA may enhance benign apical fibrosis after radiation therapy and should not, in and of itself, be used as evidence of recurrent malignancy.

Gadolinium. The new gold standard for diagnosing cerebellopontine angle tumors.

All physicians involved with the diagnosis and management of patients with tumors in the temporal bone and cerebellopontine angle are faced with the challenge removing these tumors while preserving hearing. Part of the challenge is to make the diagnosis while the tumor is still small enough to attempt a hearing-conservation surgical approach. Air-contrast (air cisternography) computed tomography is the "gold standard" by which all techniques of diagnosis are compared. Most physicians, however, are reluctant to use this test as a screen for tumors because of the associated morbidity, time, and expense. We present three case reports of contrast-enhanced magnetic resonance imaging for the detection of small intracanalicular or cerebellopontine angle tumors, and review the literature of this new and exciting technology. We feel that gadolinium-enhanced magnetic resonance imaging is now the procedure of choice for evaluating patients with suspected temporal bone tumors.

Mineralization of the basal ganglia detected by CT in Hallervorden-Spatz syndrome.

We studied a patient with autopsy-proven Hallervorden-Spatz syndrome (HSS) and the previously unreported finding of high-density lesions in the basal ganglia on CT. The diagnosis of HSS should be considered in a patient with dystonia and basal ganglia mineralization on CT.

Randomized phase III trial of single versus multiple chemotherapeutic treatment following surgery and during radiotherapy for patients with anaplastic gliomas.

In 81 patients with anaplastic supratentorial gliomas, single versus multiple chemotherapeutic agents were selected for treatment following surgery and during radiotherapy in a prospective randomized study. Time to treatment failure and survival were not significantly enhanced by multiple agent chemotherapy, as administered in this study.

Central neurotoxicity following intracarotid BCNU chemotherapy for malignant gliomas.

Central neurotoxicity is reported in 5 of 16 patients with recently diagnosed anaplastic gliomas, who received intra-arterial BCNU (200 mg/M2/course) and also 2 in a series of 26 patients with recurrent gliomas similarly treated. Neurotoxicity was usually delayed, commencing several weeks following the second or third course. CT scans during central neurotoxicity represented 1 or more of 3 patterns: no change; increased low density area(s); and/or ipsilateral gyral enhancement and punctate calcification in the middle cerebral artery territory. In one clinicopathological correlation, coagulative necrosis of the white matter was observed, identical histologically to those changes recognized as delayed vascular events following radiotherapy. Cautious exploration of the various clinical factors that may contribute to this toxicity seems appropriate, as exploration of the potential benefits of regional chemotherapeutic infusions is undertaken.

Immunobiology of primary intracranial tumors. Part 10: Therapeutic efficacy of interferon in the treatment of recurrent gliomas.

Human lymphoblastoid alpha-interferon was administered intravenously or intramuscularly to 19 patients with recurrent gliomas. Each patient had previously undergone surgery and radiation therapy. The treatment course consisted of 8 weeks of therapy with an escalating daily dosage and number of days of treatment per week to a total dose of 900 X 10(6) U/sq m. Response to treatment was determined by serial computerized tomography (CT) scans. Seven of the 17 evaluable patients were determined to be treatment responders at 12 weeks (1 month after completion of treatment), and the other 10 patients exhibited tumor progression during this period. Median survival time was 511 days for the responders versus 147 days for the non-responding patients. Interferon appears to be efficacious in the treatment of recurrent anaplastic gliomas as defined by CT brain scan responses following therapy.

Interferon as adjuvant therapy with initial radiotherapy of patients with anaplastic gliomas.

In a group of nine patients with anaplastic gliomas, survival following surgery and treatment with interferon and radiotherapy was comparable to survival for a matched group of patients treated with BCNU and radiotherapy following surgery.

Spinal subdural empyema: diagnosis by spinal computed tomography.

The authors describe the use of metrizamide spinal computed tomography scan to delineate the surgical extent of spinal subdural empyema in a 65-year-old diabetic female.

Immunobiology of primary intracranial tumors: IX. Phase I study of human lymphoblastoid interferon.

Interferon was administered intravenously on 3 consecutive days each week for 3 consecutive weeks in doses escalated each week from 10 to 20 to 30 megaunits (MU)/m2/day. Nine adult patients were treated, each of whom had undergone subtotal resection of a supratentorial anaplastic glioma within 3 weeks of beginning interferon treatment. Patients ranged in age from 34 to 71 years, and Karnofsky functional scores were 70 or greater. Evaluations included neurological examination, Karnofsky functional rating, computerized tomography brain scanning, and panels of hematologic, hepatic, renal, and coagulation testing. No dose-limiting or prohibitive toxicities were encountered, and each patient received nine interferon doses as scheduled. There were no symptoms of neurologic toxicity other than transient lethargy. Chills and fever occurred in all patients, while headache, lethargy, and back pain were experienced by half. These symptoms were most pronounced with the initial dose of each week and did not intensify with dose escalation. The most frequent side effect of interferon treatment was fever, usually peaking near the end of the initial 4-h infusion; it became less severe during the second and third weeks. Leukopenia and granulocytopenia were mild. Serum hepatic enzyme levels rose slightly during the course of interferon treatment and returned to normal after treatment was completed. Serum interferon levels reached a maximum concentration of 2,285 U/ml at the end of infusion and were proportional to the dosage. Interferon was not detectable in lumbar cerebrospinal fluid, but fluid from the tumor bed of one patient contained 120 U/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of metrizamide myelography.

Adverse neurobehavioral reactions have not been emphasized as a complication of metrizamide myelography. We encountered six such reactions in approximately 250 metrizamide myelograms. All reactions followed either cervical myelography or panmyelography via lumbar puncture. We also treated a single case of tonic-clonic seizure after intracranial spill of metrizamide in a patient without a history of seizure disorder, and a case of myoclonus following a thoracic metrizamide myelogram that showed a highgrade block. Metrizamide should not be used if an intrathecal block is suspected, or if the location to be studied makes intracranial spill difficult to avoid.

Intracranial hemorrhage following attempted embolization and removal of large arteriovenous malformations.

Two cases of intracranial hemorrhage following staged flow reduction procedures for large arteriovenous malformations are presented. Possible causes of bleeding in these cases are discussed. We suggest that the staged removal of large arteriovenous malformations may not prevent hemorrhagic complications in certain cases.

Use of metrizamide in computerized tomography to diagnose the Chiari I malformation.

To properly diagnose and treat the Chiari I malformation, it is necessary to know: 1) the position of the cerebellar tonsils; 2) the degree of compression of the upper cervical cord and medulla; 3) the status of the spinal cord, particularly whether a syringohydromyelic condition exists; 4) whether basal arachnoiditis is present; 5) the nature of the communication between the fourth ventricle and the subarachnoid space; and 6) the overall ventricular size. The use of computerized tomography (CT) alone is not sufficient to furnish all of this information. The addition of metrizamide to the CT study enables the exact delineation of the basic pathology of the Chiari I malformation and its associated complications. A total of seven patients with surgically proven Chiari I malformation were included in this study. In all of these cases, CT with metrizamide was the essential diagnostic procedure. Plain films appear to be necessary only to facilitate the diagnosis of an associated Klippel-Feil syndrome or scoliosis.

Traumatic dissection of the internal carotid artery treated by ECIC anastomosis.

A patient with traumatic dissection of the left internal carotid artery (ICA) was treated by extracranial-intracranial (ECIC) anastomosis. Anastomosis was performed because the near total occlusion of the left ICA was associated with a cerebral transient ischemic attack. At surgery, an embolus was found in a cortical branch of the middle cerebral artery and was removed at the time of the ECIC. Traumatic dissection of the ICA is briefly reviewed.

Varied CT appearance of aneurysms of the vein of Galen in infancy.

An aneurysm of the vein of Galen can have a varied CT appearance in infancy. The classical picture is a spherical posterior third ventricular mass with the density of circulating blood contiguous with a dilated straight sinus and with uniform contrast enhancement. With varying degrees of thrombosis of the aneurysm which may occur in late infancy, the mass can change in density and the dilated straight sinus disappear. With total thrombosis, a precontrast hyperdense rim develops with a low density. The rim enhances but the low density center does not change with contrast infusion. Our experience in three patients with this spectrum of CT findings will be demonstrated and correlated with clinical findings and angiography.

CT recognition of subcortical hematomas.

Subcortical hematomas develop in brain trauma and less commonly in hypertensive intracerebral hemorrhage. Six cases are reported that exhibit a spectrum of computed tomographic (CT) findings in this entity. Pathologic correlates in four cases are presented. It is theorized that subcortical hematomas form in trauma secondary to shearing stresses in the brain. Differential movement of gray and white matter may disrupt cortical medullary vessels. Rupture of degenerative vessels at this junction may account for hypertensive hematomas.