Biomedical subjects
Publications and source records attributed to H F Pribram.
A patient with a congenital arteriovenous fistula between the middle meningeal artery and a cortical vein with a giant venous varix is described. The patient presented with an intracerebral hemorrhage that had been evacuated. Permanent cure of the fistula was achieved without morbidity by embolization with Ivalon particles.
The case of a 44-year-old woman with tinnitus of her left ear is presented. An arteriogram demonstrated a posterior dural arteriovenous malformation (AVM) on that side with drainage via dilated cortical veins into the superior sagittal sinus. No intervention was undertaken. When angiography was repeated 7 years later, no dural AVM was seen.
A patient who sustained a gunshot wound to the neck and subsequent blunt trauma is presented. No angiogram was performed after the initial injury. Subsequently, the patient developed a cerebral embolus from a thrombus dislodged from a pseudoaneurysm of the cervical carotid artery, resulting in complete occlusion of the distal internal carotid artery. After antiplatelet therapy, the distal internal carotid artery recanalized, and the pseudoaneurysm occluded spontaneously. We stress the need for the use of arteriography in the initial evaluation of penetrating injuries to the neck and the utility of repeated arteriograms for further treatment planning as these traumatic lesions can change with time.
Traumatic injuries to the head and neck that result in arteriovenous fistulae are often difficult to treat by direct surgical access. This is because of anatomic location, instability of the acutely injured patient, and difficulty in localizing the exact site of injury. Between 1974 and 1988, 234 consecutive cases of traumatic injuries to the carotid or vertebral artery were evaluated by our group for intravascular embolization therapy. This included 206 cases of direct and seven cases of indirect carotid-cavernous sinus fistulae and 21 cases of traumatic vertebral fistulae. A variety of devices including detachable balloons, liquid tissue adhesives, microcoils, and silk suture were used with the goal of fistula occlusion and preservation of the parent vessel. This was achieved in 193 cases (82%). In the remaining 41 cases (18%), the carotid or vertebral artery had to be occluded by endovascular occlusion techniques because of extensive vascular injury in 28 cases and subtotal occlusion of the fistula in 13 cases. Complications included transient cerebral ischemia in six cases, pseudoaneurysm formation in five cases, stroke in five cases, and peripheral nerve injury in one case. The development of interventional neurovascular techniques has altered the management of these acutely injured patients. The preferred method for treatment has shifted from direct surgical access under general anesthesia to endovascular therapy under local anesthesia.
Optic nerve glioma in patients with neurofibromatosis is a relatively benign neoplasm. It is slow growing and considered by some to be a hamartoma. Clinical presentation usually includes loss of vision and gradual, painless proptosis. We report a case in which abrupt proptosis of the right eye was shown on magnetic resonance imaging to be due to a hemorrhage into the tumor.
A 3-year-old boy with a septated syrinx and several other dysraphic features is presented. The literature regarding the cause, diagnosis, and pathology of septation in syringomyelia is reviewed. This case raises two points. First, the septated pattern may be associated with an elevated pressure in the syrinx. Second, despite the septations, the syrinx may communicate freely.
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From 1974 to 1986, 148 patients with carotid cavernous fistula (CCF) were evaluated for intravascular therapy. Four patients died from hemorrhage before treatment could be instituted and the CCF closed spontaneously in 5. Therapeutic approaches which resulted in complete occlusion in the remaining 139 cases were transarterial in 118, transvenous in 15 and external compression of the carotid artery and jugular vein in 6. The current treatment of choice of the direct CCF is intravascular embolization using detachable balloons, particulate emboli or liquid adhesive agents to occlude the CCF while attempting to preserve the carotid artery. In 15 patients it was technically too difficult to use the transarterial approach. The patients were therefore treated from a transvenous approach including access via the femoral vein, superior ophthalmic vein, intraoperatively from the inferior petrosal sinus or direct puncture of the cavernous sinus. Embolic agents used included detachable silicone balloons, steel minicoils, particulate emboli and isobutyl-2-cyanoacrylate. In 14 of these 15 patients total obliteration was achieved with marked improvement in symptoms. Complications occurred in 3 patients including perforation of the cavernous sinus resulting in subarachnoid hemorrhage, delayed pontine hemorrhage from subtotal occlusion of the fistula and transient increased proptosis.
The authors are reporting a total of 41 patients undergoing percutaneous transluminal angioplasty (PTA) at different levels of the carotid artery. The procedure for proximal carotid artery was performed on 17 patients, for mid or distal common carotid artery on 4 patients, for carotid bifurcations on 5 patients, for internal carotid artery on 6 patients, for external carotid artery on 4 patients, and for fibromuscular dysplasia of the internal carotid artery on 5 patients. We also collected research on an additional 53 patients from the literature for a total of 94 patients. To date, we have not encountered any mortalities nor neurologic complications in performing this procedure. Thus, we believe that PTA may be performed with reasonable safety and as an alternate procedure in the treatment of carotid artery stenosis.
Osteochondromas are unusual in the spine, and they are very rarely present with compression of the spinal cord. Two cases are reported with delineation of the tumor by metrizamide myelography and computed tomography.
The authors are reporting their experience with arterial digital subtraction angiography to monitor particular intravascular embolization in hypervascular tumors and malformations and angioplasty. Arterial digital subtraction angiography may reduce the time of waiting for regular film developing and subtraction. The smaller amount of contrast material being used in arterial digital subtraction angiography minimizes the discomfort to the patients. It also prevents further renal damage in those patients with poor renal function. The arterial digital subtraction angiography may detect the early warning signs of embolotherapy. From the past experience, the authors have found that arterial digital subtraction angiography should be considered as a better alternative way to performing the particulate embolization and angioplasty than being monitored by conventional angiography.
We describe a new method for relieving biliary obstruction due to malignant solid tumors. The method consists of placement of radium needles in a Ring biliary drainage catheter for three days. After removing the radium needles, the catheter is left in place to allow for repair of irradiated tissues, then it is removed. The object is to leave the patient with a patent biliary tree without a biliary drainage prosthesis. The clinical course of six patients treated by this method is described, and the autopsy findings in three cases are outlined. Three patients died with a serum total bilirubin ranging from 1--4.5 mg/100 ml, two to three months after removing the drainage catheter. Two patients died before the bile drainage catheter could be removed. One patient is alive with a bile drainage catheter in place. Possible modifications in technique and catheters are being considered.
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Adenocarcinoma of the prostate commonly metastasizes to lymph nodes and bones, with occasional visceral deposits; lesions in the brain are rare. Although leptomeningeal carcinomatosis secondary to prostatic tumor has been reported, discrete cranial dural metastases from prostatic adenocarcinoma have not been described previously. The case of a patient having a unique adenocarcinoma of the prostate with bone, lymph node, and subdural metastatic lesions is presented.
Three patients with progressive supranuclear palsy demonstrated atrophy of the midbrain, pons, cerebellum, and cerebral hemispheres by computed tomography with horizontal, sagittal, and coronal reconstruction. Benztropine therapy resulted in improvement of speech and gait without significantly affecting the vertical gaze palsy.
Embolization of very vascular meningiomas prior to operation will reduce the loss of blood during operation. The technique of preoperative embolization is discussed, and 11 cases are presented.
The incidental finding of an enlarged sella turcica on a skull roentgenogram may precipitate a tedious, expensive endocrinological as well as invasive radiological evaluation of an asymptomatic patient. Computed tomography and metrizamide cisternography have been suggested as alternatives to traditional pneumoencephalography. We have found the most direct and definitive study of the "empty sella" to be limited computed tomography after the introduction of a small amount of air by lumbar puncture. The diagnosis is made quickly without morbidity.
A sensitive method for localizing the resting place of catheter-injected therapeutic gelatin emboli is described. Surgical gelatin (Gelfoam) is labeled with 99mTc and each embolus observed on the persistence scope of a gamma camera after injection. This technique reduces the chance of obstructing blood vessels other than those intended. Two cases of embolization, one arterial and one venous, are illustrated.