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Point-of-care ultrasound (POCUS) has become an essential part of the evaluation of vision loss among emergency physicians in the emergency department (ED). It is frequently used to evaluate for vitreous hemorrhage, foreign bodies, retinal detachment, optic neuritis and posterior vitreous detachment; however, it can also be used to evaluate for a central retinal artery occlusion (CRAO). A POCUS can reveal a hyperechoic density in the optic nerve sheath just proximal to the retinal surface, and this is referred to as a retrobulbar 'spot sign' (RBSS). We present the case of an 88-year-old male that presented to our community ED with a painless loss of vision to his right eye. A POCUS revealed an RBSS of the central retinal artery and he was subsequently diagnosed with a CRAO. At his 1-month follow-up, he has regained light perception and 15% of his vision, however, remains with significant visual impairment., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: The authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm., Methods: In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist., Results: There was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 178 clip-assigned patients with saccular aneurysms, 1 (< 1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow-up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time., Conclusions: There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov).

OBJECTIVE The Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions. METHODS The primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment. RESULTS Of the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10). CONCLUSIONS In the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling. Clinical trial registration no.: NCT01593267 (clinicaltrials.gov).

Public health researchers have used a class of statistical methods to calculate prevalence estimates for small geographic areas with few direct observations. Many researchers have used Behavioral Risk Factor Surveillance System (BRFSS) data as a basis for their models. The aims of this study were to 1) describe a new BRFSS small area estimation (SAE) method and 2) investigate the internal and external validity of the BRFSS SAEs it produced. The BRFSS SAE method uses 4 data sets (the BRFSS, the American Community Survey Public Use Microdata Sample, Nielsen Claritas population totals, and the Missouri Census Geographic Equivalency File) to build a single weighted data set. Our findings indicate that internal and external validity tests were successful across many estimates. The BRFSS SAE method is one of several methods that can be used to produce reliable prevalence estimates in small geographic areas.

Object: The authors report the 6-year results of the Barrow Ruptured Aneurysm Trial (BRAT). This ongoing randomized trial, with the final goal of a 10-year follow-up, compares the safety and efficacy of surgical clip occlusion and endovascular coil embolization in patients presenting with subarachnoid hemorrhage (SAH) from a ruptured aneurysm. The 1- and 3-year results of this trial have been previously reported., Methods: In total, 500 patients with an SAH met the entry criteria and were enrolled in the study. Of these patients, 471 were randomly assigned to the treatments: 238 to surgical clipping and 233 to endovascular coiling. Six patients who died before treatment and 57 patients with nonaneurysmal SAHs were excluded, leaving a total of 408 patients who underwent clipping (209 assigned) or coiling (199 assigned). Whether to treat patients within the assigned group or to cross over patients to the other group was at the discretion of the treating physician; 38% (75/199) of the patients assigned to coiling were crossed over to clipping and 1.9% (4/209) assigned to clipping were crossed over to coiling. The outcome data were collected by a dedicated nurse practitioner. The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. Six years after randomization, 336 (82%) of 408 patients who had been treated were available for examination., Results: On the basis of an mRS score of > 2, and similar to the results at the 3-year follow-up, no significant difference in outcomes (p = 0.24) was detected between the 2 treatment groups. Complete aneurysm obliteration at 6 years was achieved in 96% (111/116) of the clipping group and in 48% (23/48) of the coiling group (p < 0.0001). In the period between the 3- and 6-year follow-ups, 3 additional patients assigned to coiling and none assigned to clipping received retreatment, for overall retreatment rates of 4.6% (13/280) for clipping and 16.4% (21/128) for coiling (p < 0.0001). When aneurysm location was considered, the 6-year results continued to match the previously reported results, with no difference in outcome for anterior circulation aneurysms at most time points. Of the anterior circulation aneurysms assigned to coiling treatment, 42% (70/168) were crossed over to clipping treatment. The outcomes for posterior circulation aneurysms continued to favor coiling. The randomization process was unexpectedly skewed, with 18 of 21 treated aneurysms of the posterior inferior cerebellar artery (PICA) being assigned to clipping, but even when PICA aneurysms were removed from the analysis, outcomes for the posterior circulation aneurysms still favored coiling., Conclusions: Although BRAT was statistically underpowered to detect small differences, these results suggest little difference in outcome between the 2 treatments for anterior circulation aneurysms. This was not the case for the posterior circulation aneurysms, where coil embolization appeared to provide a sustained advantage over clipping. Aneurysm obliteration rates in BRAT were significantly lower and retreatment rates significantly higher in the patients undergoing coiling than in those undergoing clipping. However, despite the fact that retreatment rates were higher after coiling, no recurrent hemorrhages were known to have occurred in patients undergoing coiling in BRAT who were followed up for 6 years. Sufficient questions remain about the relative benefits of the 2 treatment modalities to warrant further well-designed randomized trials.

Object: The authors report the 3-year results of the Barrow Ruptured Aneurysm Trial (BRAT). The objective of this ongoing randomized trial is to compare the safety and efficacy of microsurgical clip occlusion and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to compare functional outcomes based on clinical and angiographic data. The 1-year results have been previously reported., Methods: Two-hundred thirty-eight patients were assigned to clip occlusion and 233 to coil embolization. There were no anatomical exclusions. Crossovers were allowed based on the treating physician's determination, but primary outcome analysis was based on the initial assignment to treatment modality. Patient outcomes were assessed independently using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score>2. At 3 years' follow-up 349 patients who had actually undergone treatment were available for evaluation. Of the 170 patients who had been originally assigned to coiling, 64 (38%) crossed over to clipping, whereas 4 (2%) of 179 patients assigned to surgery crossed over to clipping., Results: The risk of a poor outcome in patients assigned to clipping compared with those assigned to coiling (35.8% vs 30%) had decreased from that observed at 1 year and was no longer significant (OR 1.30, 95% CI 0.83-2.04, p=0.25). In addition, the degree of aneurysm obliteration (p=0.0001), rate of aneurysm recurrence (p=0.01), and rate of retreatment (p=0.01) were significantly better in the group treated with clipping compared with the group treated with coiling. When outcomes were analyzed based on aneurysm location (anterior circulation, n=339; posterior circulation, n=69), there was no significant difference in the outcomes of anterior circulation aneurysms between the 2 assigned groups across time points (at discharge, 6 months, 1 year, or 3 years after treatment). The outcomes of posterior circulation aneurysms were significantly better in the coil group than in the clip group after the 1st year of follow-up, and this difference persisted after 3 years of follow-up. However, while aneurysms in the anterior circulation were well matched in their anatomical location between the 2 treatment arms, this was not the case in the posterior circulation where, for example, 18 of 21 posterior inferior cerebellar artery aneurysms were in the clip group., Conclusions: Based on mRS scores at 3 years, the outcomes of all patients assigned to coil embolization showed a favorable 5.8% absolute difference compared with outcomes of those assigned to clip occlusion, although this difference did not reach statistical significance (p=0.25). Patients in the clip group had a significantly higher degree of aneurysm obliteration and a significantly lower rate of recurrence and retreatment. In post hoc analysis examining only anterior circulation aneurysms, no outcome difference between the 2 treatment cohorts was observed at any recorded time point. CLINICAL TRIAL REGISTRATION NO.: NCT01593267 ( ClinicalTrials.gov ).

Background: The rationale for choosing between the condylar fossa and transcondylar variations of the far-lateral approach requires understanding of the relationships between the occipital condyle, jugular tubercle, and hypoglossal canal., Objective: We examined the anatomic relationship of these 3 structures and analyzed the effect that changes in these relationships have on the surgical exposure and angle of attack for these 2 approaches., Methods: Anatomic measurements of 5 cadaveric heads from 3-dimensional computed tomographic scans were compared with direct measurements of the same specimens. The condylar fossa and transcondylar approach were performed sequentially in 8 of 10 sides. Surgical exposure and angle of attack were measured after each exposure., Results: The jugular tubercle (JT) angle (JTA) measures the angle formed by reference points on the condyle, hypoglossal canal, and JT. When the JT and occipital condyle are not prominent (JTA > 180 degrees ), the transcondylar approach does not significantly increase petroclival or brainstem exposure compared with the condylar fossa approach; however, it does significantly increase the angle of attack to the junction of the posterior inferior cerebellar and vertebral arteries and the surgical angle for the medial part of the JT (P < .05)., Conclusion: The condylar fossa and transcondylar approaches provide similar exposures of the petroclivus and brainstem when the JT and occipital condyle are not prominent (JTA > 180 degrees on 3-dimensional computed tomographic). However, for lesions below the hypoglossal canal, the transcondylar approach is preferred because it significantly increases the angle of attack.

Object: There are few systematic investigations of the dissected surgical anatomy of the diploic venous system (DVS) in the neuroanatomical literature. The authors describe the DVS relative to different common neurosurgical approaches. Knowledge of this system can help avoid potential sources of unacceptable bleeding and may impact healing of the cranium., Methods: Using a high-speed drill with a 2-mm bit, the authors removed the outer layer of the compact bone in the skull to expose the DVS in 12 formalin-fixed cadaver heads. Pterional, supraorbital, and modified orbitozygomatic craniotomies were performed to delineate the relationship of the DVS., Results: The draining point of the frontal diploic vein (FDV) was located near the supraorbital notch. The draining point of the anterior temporal diploic vein (ATDV) was located in all pterional areas; the draining point of the posterior temporal diploic vein (PTDV) was located in all asterional areas. The PTDV was the dominant diploic vessel in all sides. The FDV and ATDV could be damaged during supraorbital, modified orbitozygomatic, and pterional craniotomies. The anterior DVS connected with the sphenoparietal and superior sagittal sinus (SSS). The posterior DVS connected with the transverse and sigmoid sinuses and was the dominant diploic vessel in all 24 sides. Of all the major diploic vessels, the location and pattern of distribution of the FDV were the most constant. The parietal bone contained the most diploic vessels. No diploic veins were found in the area delimited by the temporal squama., Conclusions: The pterional, orbitozygomatic, and supraorbital approaches place the FDV and ATDV at risk. The major anterior diploic system connects the SSS with the sphenoparietal sinus. The posterior diploic system connects the SSS with the transverse and sigmoid sinuses.

Conventional catheter-based angiography, magnetic resonance imaging/angiography, and computed tomographic angiography are all techniques routinely practiced for the diagnosis of aneurysms. With regard to the evaluation of treated aneurysms, each of these imaging modalities has inherent advantages and disadvantages. This review was aimed to provide a better understanding of the optimal application and interpretation of the available imaging modalities for the assessment of treated cerebral aneurysms.

Although not useful for the evaluation of coiled aneurysms, CT angiography (CTA) is far superior to MR angiography (MRA) for the evaluation of aneurysms after surgical clipping. Using the latest multidetector row scanners and optimized imaging parameters, CTA can often effectively depict and follow small aneurysm remnants; demonstrate patency, stenosis, or vasospasm in the adjacent parent vessels; and provide surveillance of the entire cerebrovasculature for de novo aneurysms after surgical clipping. Despite these advances, conventional angiography remains the gold standard for the evaluation of surgically treated aneurysms and should be liberally used to resolve any cases of diagnostic uncertainty on noninvasive imaging.

MRA is emerging as an alternative to conventional catheter based angiography for the assessment of aneurysms after endovascular treatment. Short TE and contrast enhanced MRA techniques can be applied to optimize image quality. We review the available data regarding the application of MR for the assessment of cerebral aneurysms after endovascular therapy.

Background and Purpose: Imaging characteristics of temporal bone meningioma have not been previously reported in the literature. CT and MR imaging findings in 13 cases of temporal bone meningioma are reviewed to define specific imaging features., Methods: A retrospective review of our institutional case archive revealed 13 cases of histologically confirmed temporal bone meningioma. CT and MR imaging studies were reviewed to characterize mass location, vector of spread, bone changes, enhancement characteristics, and intracranial patterns of involvement. Clinical presenting signs and symptoms were correlated with imaging findings., Results: Thirteen temporal bone meningiomas were reviewed in 8 women and 5 men, aged 18-65 years. Meningiomas were stratified into 3 groups on the basis of location and tumor vector of spread. There were 6 tegmen tympani, 5 jugular foramen (JF), and 2 internal auditory canal (IAC) meningiomas. Tegmen tympani and JF meningiomas were characterized by spread to the middle ear cavity. IAC meningiomas, by contrast, spread to the cochlea and vestibule. Hearing loss was the most common clinical presenting feature in all cases of temporal bone meningioma (10/13). The presence of tumor adjacent to the ossicles strongly correlated with conductive hearing loss (7/9)., Conclusion: Meningioma involving the temporal bone is rare. Three subgroups of meningioma exist in this location: tegmen tympani, JF, and IAC meningioma. Tegmen tympani and JF meningiomas spread to the middle ear cavity. IAC meningiomas spread to intralabyrinthine structures. Conductive hearing loss is commonly seen in these patients and can be surgically correctable.

Introduction: Isolated spinal aneurysms are rare; only a few have been reported. To the best of our knowledge, this series represents the largest experience with four ruptured spinal aneurysms, all of which were treated surgically., Methods: Clinical information from the hospital charts and diagnostic images of four patients with the diagnosis of spinal aneurysms were reviewed from the senior authors' (RFS, JMZ) office database, surgical reports, and radiological imaging database. Follow-up examinations were performed by phone interview, when possible, and by chart review., Results: Between 1997 and 2004, four patients with ruptured spinal aneurysms underwent surgical treatment. All aneurysms were located within the spinal canal and manifested with spinal subarachnoid hemorrhage. No collagen disease, aortic coartaction, arteriovenous fistula, or arteriovenous malformations were identified in these patients., Conclusion: Subarachnoid hemorrhage within the spinal cord can be caused by ruptured aneurysms. Spinal aneurysms are rare, but should be considered within the differential diagnosis of patients with intracranial subarachnoid hemorrhage when cranial angiography is negative. Magnetic resonance imaging and selective spinal angiography are useful for workup, but definitive diagnosis may require surgical exploration.

Spinal artery aneurysms are usually found with arteriovenous malformations or other entities that increase hemodynamic stress. Isolated spinal artery aneurysms are rare. Four patients who presented with the acute onset of lower back pain underwent MR imaging, which revealed spinal subarachnoid hemorrhage. In all patients, work-up yielded a diagnosis of isolated spinal aneurysm, and operative treatment was successful. In the appropriate clinical setting, spinal aneurysm should be considered as a possible cause of spinal subarachnoid hemorrhage.

Background and Purpose: Dissection and retraction of the sylvian fissure can cause venous insufficiency and may be an important contributor to postoperative edema or hemorrhage after clipping of a middle cerebral artery (MCA) aneurysm. The incidence of changes in the superficial middle cerebral vein (SMCV) and adjacent veins and whether such changes increase the amount of edema or hemorrhage on postoperative CT is the focus of this study., Methods: Pre- and postoperative angiograms of 100 consecutive patients with MCA aneurysms treated by craniotomy and clipping were compared to determine the postoperative incidence of changes involving the SMCV. CTs from the normal and abnormal postoperative venous groups were compared to determine the amount of edema or presence of parenchymal hemorrhage., Results: Postoperatively, 31 (31%) SMCVs were altered, 20 to a minor or moderate degree. Eleven cases were pronounced. In 9 (9%) cases, the SMCV was completely obscured or failed to fill on postoperative angiography. More edema (observer 1, P < .0002; observer 2, P < .0006) and small brain parenchymal hemorrhages (observer 1, P < .00003; observer 2, P < .00001) were found on the postoperative CT images of the group whose SMCVs were altered than those that were unchanged., Conclusions: Neurosurgeons and neuroradiologists should be attentive to changes in the SMCV and adjacent venous structures to optimize outcomes of procedures involving the sylvian fissure.

Objective: To evaluate the safety profile of platelet glycoprotein IIb/IIIa inhibitors administered as adjunctive therapy to patients with large-vessel occlusion and acute ischemic stroke refractory to pharmacological thrombolysis with recombinant tissue plasminogen activator (rtPA) and mechanical disruption, balloon angioplasty, or both., Methods: Twenty-one patients (mean age, 62 yr; range, 29-88 yr) met the following criteria: 1) large-vessel occlusion and acute ischemic stroke syndrome at presentation, 2) failure to recanalize after administration of rtPA (intra-arterial and/or intravenous) with or without mechanical thrombolysis, and 3) subsequent treatment with IIb/IIIa inhibitors (intra-arterial or intravenous)., Results: Eleven patients had ischemia in the dominant hemisphere, 8 in the vertebrobasilar system, and 2 in the nondominant hemisphere. Twelve patients received intravenous rtPA without significant improvement; 9 patients were not candidates for intravenous rtPA. All patients received intra-arterial rtPA. The IIb/IIIa inhibitors were administered intravenously in 3 patients, intra-arterially in 16, and both intravenously and intra-arterially in 2. Balloon angioplasty was performed in 18 patients. Complete or partial recanalization was achieved in 17 of the 21 patients. After thrombolysis, 15 improved clinically. Three patients (14%) sustained an asymptomatic intracerebral hemorrhage after thrombolytic therapy. No patient was clinically worse after intervention. At last follow-up (mean, 8.5 mo), 13 patients were functionally independent (modified Rankin score, 0-3) and 8 were disabled or dead., Conclusion: IIb/IIIa inhibitors are an alternative for achieving recanalization. The risk of hemorrhage may be low. As part of an escalating protocol that includes pharmacological and mechanical thrombolysis, IIb/IIIa inhibitors may improve clinical outcomes.

Object: The authors sought to establish radiological criteria for the diagnosis of C1-2 vertical distraction injuries., Methods: Conventional radiography, computerized tomography (CT), and magnetic resonance (MR) imaging findings in five patients with a C1-2 vertical distraction injury were correlated with their clinical history, operative findings, and autopsy findings. The basion-dens interval (BDI) and the C-1 and C-2 lateral mass interval (LMI) were measured in 93 control patients who underwent CT angiography; these measurements were used to define the normal BDI and LMI. The MR imaging results obtained in 30 healthy individuals were used to characterize the normal signal intensity of the C1-2 joint. The MR imaging results were compared with MR images obtained in five patients with distraction injuries. In the 93 patients, the BDI averaged 4.7 mm (standard deviation [SD] 1.7 mm, range 0.6-9 mm) and the LMI averaged 1.7 mm (SD 0.48 mm, range 0.7-3.3 mm). Based on CT scanning in the five patients with distraction injuries, the BDIs (mean 11.9 mm, SD 3.2 mm; p < 0.001) and LMIs (mean 5.5 mm, SD 2 mm; p < 0.0001) were significantly greater than in the control group. Fast-spin echo inversion-recovery MR images obtained in these five patients revealed markedly increased signal distributed throughout the C1-2 lateral mass articulations bilaterally., Conclusions: In 95% of healthy individuals, the LMI ranged between 0.7 and 2.6 mm. An LMI greater than 2.6 mm indicates the possibility of a distraction injury, which can be confirmed using MR imaging. Patients with a suspected C1-2 distraction injury may be candidates for surgical fusion of C1-2.

We report a case of genetically verified Charcot-Marie-Tooth disease in which the patient had cranial nerve symptoms. CT and MR imaging demonstrated enlargement of several cranial nerves, as well as their skull-base foramina, with faint contrast material enhancement identified.

Background: Undiagnosed HIV infection is prevalent among patients who present to urban emergency departments (EDs). Providing appropriate counseling, testing, and follow-up in the ED is difficult. The aim of this study was to evaluate the effectiveness of a referral-based outpatient HIV testing system for patients referred from the ED., Methods: This was a prospective cohort study performed at an urban teaching hospital. Consecutive patients referred from the emergency department (ED) for outpatient HIV testing were enrolled. Data were collected from each patient's ED record and HIV clinic record, if applicable., Results: Of the 586 referrals made from our ED, 494 (84%) met inclusion criteria. Only 56 patients (11%, 95% CI: 9-15%) arrived at the HIV clinic and completed pretest counseling. Of these, 51 (91%, 95% CI: 80-97%) tested negative for HIV, 4 (7%, 95% CI: 2-17%) tested positive for HIV, and 1 (2%, 95% CI: 0-10%) refused the test., Conclusions: This referral system was ineffective at identifying unrecognized HIV infection due to poor adherence. Changes in the structure of the referral system or the use of point-of-care testing in the ED may improve the ability to detect HIV infection in this setting.

An 18-year-old female patient with unilateral hearing loss underwent evaluation with CT and MR imaging. A partially ossified, enhancing lesion in the bony labyrinth, with replacement of adjacent structures, was identified. Surgical biopsy revealed a meningioma arising primarily within the bony labyrinth. To our knowledge, this entity has not been previously described.

Imaging the skull base after surgery can be challenging because anatomic structures may have been destroyed by an underlying process or removed at surgery. Foreign substances may be introduced to fill a void left by tumor resection, for hemostasis, and to repair dural defects. Previous imaging studies must be available for comparison to understand the characteristics of an underlying lesion. By following the progression of a lesion on subsequent imaging studies, the nature of treatment-related changes and residual or recurrent pathology is best realized.

Objective: To examine the reliability of using the optic strut as a landmark in computed tomographic (CT) angiography, to differentiate between intradural and extradural (cavernous sinus) aneurysms involving the paraclinoid segment of the internal carotid artery (ICA)., Methods: Microanatomic dissections were performed with five cadaveric heads (10 sides), to establish the relationships of the optic strut to the cavernous sinus and the ICA. Results from these anatomic studies were compared with intraoperative and CT angiographic findings for four patients with nine intracranial aneurysms involving the paraclinoid segment of the ICA., Results: The inferior boundary of the optic strut accurately localized the point at which the ICA pierced the oculomotor membrane (proximal dural ring) and exited the cavernous sinus. The optic strut and its relationship to the ICA could be well observed on CT angiograms. During surgery, six of six aneurysms that arose distal to the optic strut were identified intradurally and were successfully clipped. Conversely, all aneurysms that arose proximal to the optic strut were observed to lie within the cavernous sinus. An aneurysm at the optic strut was within the clinoid segment or interdural, between the proximal and distal rings., Conclusion: The optic strut, as identified with CT angiography, provided a reliable anatomic landmark for accurate discrimination between intradural and extradural (cavernous sinus) aneurysms.

We characterized the quantity and quality of graphs in all pharmaceutical advertisements, in the 10 U.S. medical journals. Four hundred eighty-four unique advertisements (of 3,185 total advertisements) contained 836 glossy and 455 small-print pages. Forty-nine percent of glossy page area was nonscientific figures/images, 0.4% tables, and 1.6% scientific graphs (74 graphs in 64 advertisements). All 74 graphs were univariate displays, 4% were distributions, and 4% contained confidence intervals for summary measures. Extraneous decoration (66%) and redundancy (46%) were common. Fifty-eight percent of graphs presented an outcome relevant to the drug's indication. Numeric distortion, specifically prohibited by FDA regulations, occurred in 36% of graphs.

We report a rare case of intradural primary osteosarcoma (IPOS) in a 74-year-old man with aphasia and right-sided hemiparesis. Radiologic workup revealed a large, partially calcified, left-sided frontotemporal intracranial mass lesion. At surgery, the tumor was found to be entirely intradural; it involved the brain and subarachnoid space of the left sylvian fissure. The adjacent dura was uninvolved. Neuropathologic findings confirmed the diagnosis of chondroblastic osteosarcoma. To our knowledge, this is the sixth reported case of IPOS and the first reported case of the chondroblastic subtype.

Setting: Mycobacterium avium is the major cause of disseminated infection in patients with late stage AIDS., Objective: In order to identify M. avium genes that may be involved in bacterial uptake and intracellular survival, a phoA -based reporter system was used to identify genes that encoded surface-expressed or exported proteins., Design: PhoA (alkaline phosphatase) is only active if the protein is exported across the cell membrane into the periplasm. Consequently, detectable PhoA activity requires the fusion of a promoterless phoA gene with a DNA fragment containing a functional promoter and export leader sequence. A M. avium promoter library was constructed in the phoA reporter plasmid pJEM11 and screened in M. smegmatis for expression of active PhoA., Results: More than 100 independent PhoA(+)recombinants were isolated, of which 15 were sequenced. Most of these exhibited varying degrees of homology with published M. avium, M. tuberculosis, M. bovis and M. leprae sequences. Based on sequence homology, one M. avium sequence was identified as a homologue of the M. tuberculosis phosphate transport gene phoS2 (Ag88). Another M. avium sequence was homolog with a putative M. tuberculosis cutinase gene. Both of these M. avium genes were cloned and sequenced. Several other M. avium sequences were homologous with, as yet, unidentified M. tuberculosis genes., Conclusion: PhoA fusion technology is applicable to the study of atypical slow growing mycobacteria. Most of the M. avium exported proteins identified in this study are highly homologous with genes from M. tuberculosis and M. leprae. In addition, parallels in gene organization were identified between M. avium and members of the M. tuberculosis complex., (Copyright 2000 Harcourt Publishers Ltd.)

Background and Purpose: Occasionally we have observed anecdotal cases of asymptomatic hyperintensities on diffusion-weighted MR (DW-MR) examinations of the brain of patients who previously underwent routine cerebral angiography. These observations, as well as MR imaging and transcranial Doppler data in the literature suggesting a high rate of procedure-associated emboli, raise concern regarding the underdiagnosis of asymptomatic focal infarction associated with cerebral angiography. In order to determine whether asymptomatic diffusion abnormalities are frequently associated with procedures, we prospectively obtained DW-MR images before and after routine cerebral angiography., Methods: Twenty consecutive patients, who met protocol criteria and received a routine three- or four-vessel diagnostic cerebral angiogram at our institution, were evaluated. Using a Bayesian estimate to establish an upper bound for the incidence of an event with zero occurrences in a study sample, the study group size was selected to exclude a 10% incidence of abnormalities revealed by DW-MR imaging of patients who underwent previous cerebral angiography. Two neuroradiologists evaluated imaging studies., Results: Neither clinical signs nor abnormalities on DW-MR images were found, which suggested no infarction after angiography in our patient sample. Based on this data, an upper bound of 9% (95% confidence) is predicted for the appearance of abnormalities revealed by DW-MR imaging after cerebral angiography., Conclusion: Cerebral angiography is associated with an incidence of asymptomatic cerebral infarction of no more than 9%. It well may be substantially lower than this estimate; a more accurate evaluation of the true incidence would require a significantly larger study population. This test provides a convenient noninvasive means of assessing procedure-related cerebral infarction, such as that which occurs after carotid endarterectomy or vascular angioplasty and stenting.

We describe a relatively unusual case of carotid cavernous fistula in association with a persistent trigeminal artery, presumably related to aneurysm rupture near the carotid origin of the vessel. We emphasize the use of a second, nondetachable balloon solely for the purpose of stabilizing placement of the first device at the time of detachment.

Objective: To evaluate the magnetic resonance imaging results (MRI) of patients with electronystagmography (ENG) suggestive of central vestibular dysfunction and to determine if MRI abnormalities correlate with ENG findings., Study Design: Retrospective blinded case review., Setting: A regional neurotology center., Patients: Patients with ENG suggesting central vestibular dysfunction were identified (n = 30). An age-matched group of patients with normal ENG results were used as controls (n = 28)., Main Outcome Measures: MRI abnormalities in cerebellum, brain stem, cerebellar peduncles, and central ENG findings., Results: Twenty-one patients with abnormal MRI results of the vestibular pathway were found, 15 with abnormal and 6 with normal ENG results. MRI correlation with ENG findings has a better predictive value in older patients than in younger patients. Sixteen patients had MRI evidence of vascular compression, seven of whom had abnormal and nine of whom had normal ENG results., Conclusions: This study suggests that a detailed review of MRI images of the vestibular pathway is warranted, and, in patients with central ENG abnormalities, MRI may support the diagnosis of central vestibular dysfunction. MRI cannot support central vestibular dysfunction caused by vascular compression.

The diagnostic evaluation of a brain arteriovenous malformation requires a thorough understanding of the imaging features seen on CT, MR, and conventional angiography. Therapeutic planning requires a comprehensive understanding of the angioarchitecture of AVMs, necessitation selective and superselective angiography in order to give an accurate assessment of the lesion. This article will discuss the diagnostic work-up of AVMs. AVM treatment requires a multidisciplinary approach that includes interventional neuroradiology, radiosurgery, and neurosurgery. The considerations and philosophies of each discipline will discussed in order to provide the perspective required for the comprehensive treatment of AVMs.

The role of thrombolysis in brain ischemia in patients with atrial myxoma is unknown. A patient with acute brain ischemia and previously undiagnosed atrial myxoma recanalized an occluded middle cerebral artery with intra-arterial thrombolysis. Arterial occlusion from presumed myxoma may be amenable to fibrinolysis. Angiography before treatment in patients with atrial myxoma excludes a myxomatous pseudoaneurysm and permits site-specific thrombolytic instillment.

Purpose: To determine the clinical effectiveness of parent artery occlusion of the carotid or vertebral artery by means of temporary proximal flow arrest and microcoils., Methods: Nineteen parent artery occlusions (15 carotid, four vertebral) were performed in 19 patients who successfully passed a balloon test occlusion. In these patients, endovascular occlusion of the carotid or vertebral artery was accomplished with the use of temporary proximal flow arrest and microcoils., Results: All 19 parent arteries were occluded. Eighteen patients (95%) had good outcomes and one (5%) had a poor outcome. Fourteen patients (74%) had no complications and five (26%) had complications, of whom only one was left with a permanent neurologic deficit. Three (60%) of the complications were the result of delayed ischemic events after parent artery occlusion and were not predicted by balloon test occlusion., Conclusion: Endovascular occlusion with temporary proximal flow arrest and microcoils can be done effectively and successfully. The predictive value of the balloon test occlusion is the major complicating factor, as it is with balloon occlusion. This technique offers an additional tool that can be used for endovascular occlusion of the carotid or vertebral artery and seems to be less difficult technically. It is our primary technique for parent artery occlusion.

We describe the use of abciximab to prevent rethrombosis of the basilar artery after transluminal angioplasty. A 60-year-old patient with vertebral basilar insufficiency and acute occlusion of the basilar artery underwent revascularization with urokinase and angioplasty. Despite the repeated use of urokinase and angioplasty under anticoagulation with heparin, the basilar artery immediately rethrombosed. In a final attempt to prevent rethrombosis, abciximab was administered before the final angioplasty, resulting in a widely patent basilar artery and no rethrombosis.

Purpose: To evaluate the results of balloon angioplasty of 17 stenoses resulting from intracranial atherosclerosis and vasculitis., Methods: Seventeen skull-base and intracranial lesions were dilated with a microballoon angioplasty catheter., Results: Initially, 16 of the 17 stenoses showed improvement at angiography. Moderate residual stenosis was found in 2 of 12 atherosclerotic lesions, both in the distal vertebral artery. Angioplasty in 1 of 12 atherosclerotic lesions caused worsening of the stenotic site, also in the distal V4 region of the vertebral artery. All but one of the patients improved clinically. However, all five lesions caused by acute vasculitis progressed to occlusion after initial improvement., Conclusion: Intracranial percutaneous transluminal angioplasty is a viable nonsurgical option for the treatment of atherosclerotic vascular insufficiency, but it may not be as successful in treating lesions caused by vasculitis in the acute phase.

The purpose of this article is to report on the safety and effectiveness of brain arteriovenous malformation (AVM) embolization for two series of patients, of which one was treated with particulate embolization and the other with acrylic embolization. Sixty-five consecutive patients from embolization logs and patient records from 1988 to 1993 were reviewed. AVMs were routinely treated with particulate embolization early in the review (1988-1991), and after a transition period, the technique was changed to acrylic embolization for the remainder of the study period (1992-1993). All patients were treated with the ultimate goal of complete AVM obliteration. AVMs were embolized and resected, if possible, and if unresectable, they were reduced in size with embolization and radiated. The course of treatment for each patient was reviewed. The effectiveness at the end of treatment was analyzed for the ability to resect the AVM and, if unresectable, the ability to reduce the AVM to radiation size. Additionally, the safety of each embolization technique was evaluated in the context of comprehensive care, in terms of the safety of the procedure itself, the surgical resection after embolization, and the outcome at the end of comprehensive treatment. This article outlines the safety and effectiveness of acrylic and particulate embolization at a single institution. The ability to surgically resect an AVM after embolization and to reduce nidus size with acrylic was at least comparable with that with particulate embolization. Comprehensive complication rates were lower after acrylic embolization and were heavily influenced by a decreased number of surgical complications in the acrylic series. These data support the need to conduct a randomized prospective clinical trial to compare the relative safety and effectiveness of the two methods of embolization.

We present a patient with Parkinson's disease whose bilateral tremor transiently resolved after a unilateral left ventrolateral thalamotomy. The transient resolution of the bilateral tremor was associated with a focal thalamic lesion and a second lesion in the corpus callosum. The mechanism of this phenomenon may be related to temporary disruption of descending bilateral corticostriate projections by the callosal lesion.

Purpose: To evaluate the clinical efficacy, cost-effectiveness, and safety of presurgical devascularization of meningiomas., Methods: Matched samples of embolized and nonembolized groups of meningiomas were compared. The study variables for clinical efficacy were estimated blood loss, number of transfusions, surgical resection time, and length of hospitalization. The cost-effectiveness was evaluated by adjusting all hospital costs to 1991 dollar amounts, and adding additional embolization costs and fees to the hospital cost totals for the embolized group. A qualitative comparison of complications was made., Results: All dependent variables evaluating the clinical efficacy of the procedure (estimate blood loss, 533 cc versus 836 cc; number of transfusions, 0.39 units versus 1.56 units; surgical resection time, 305.8 minutes versus 337.5 minutes; and length of hospitalization, 10.6 days versus 15.0 days) displayed trends of higher means in the nonembolized group; however, only the estimated blood loss and number of transfusions variables were significant. The cost-effectiveness of the procedure was not statistically significant. The mean cost was $29,605 for the embolized group and $38,449 for the nonembolized group. There were three major and nine minor complications in the nonembolized group and zero major and six minor complications in the embolized group. There were four additional minor complications caused by the embolization procedure., Conclusion: Endovascular devascularization of meningiomas is beneficial for large meningiomas because it diminishes the necessity of intraoperative transfusions and decreases blood loss. The additional day of hospitalization, emolization costs, and costs of complications do not conversely increase treatment costs. There were no major complications or adverse long-term effects caused by the embolization procedure.

We retrospectively evaluated the CT studies of 9 children who presented with intracranial tuberculosis during 1981-1987, and compared their radiographic appearance with the clinical outcome. The most common radiographic findings were: 1) ventriculomegaly (7/9) ,2) tuberculoma formation (6/9), and 3) infarction (4/9). Of 7 patients with ventriculomegaly, 3 required a ventricular shunt and 2 had spontaneous resolution of ventricular dilatation. Four children with ventriculomegaly were moderately or severely retarded, one had cognitive dysfunction, and one was neurologically normal. Four of six children with tuberculoma also had infarction and/or ventriculomegaly; of these four children, three were moderately or severely retarded. Two patients with tuberculoma as the only intracranial abnormality had complete resolution of the granuloma with normal neurologic outcome following antituberculous therapy. The four children with large vessel infarction also had ventriculomegaly; three had poor clinical outcome. The presence of tuberculoma alone is not necessarily predictive of poor neurologic outcome; age less than 20 months, infarct, and/or ventriculomegaly are usually associated with sequelae.

Prenatal diagnoses of the genetic disorders alpha, beta thalassemia, HbS, Hb Lepore, hemophilia and cystic fibrosis were sought in 88 cases. Six unsuccessful attempts at diagnosis resulted from DNA polymorphisms which were only 50% informative (four cases) and prenatal diagnoses which had been undertaken before it was known whether DNA polymorphisms in family studies were informative (two cases). The most frequent indications for prenatal diagnosis were the hemoglobinopathies although requests for exclusion of cystic fibrosis formed the majority during 1989. Strong linkage disequilibrium between the cystic fibrosis defect and its associated DNA polymorphisms facilitated detection of this disorder. Late presentations among patients with beta thalassemia and hemophilia and the necessity for more specialised genetic counselling were the commonest problems encountered.

A simplified passive haemagglutination (PHA) screening test, an improved quantitative PHA assay, and a stable test cell preparation are described, as well as a comprehensive testing strategy which have been used in concert at this Service over the past 10 years for the successful accession of high-titre tetanus anti-toxin (TAT) plasma for fractionation into human tetanus immunoglobulin (HTIG). The sequential deployment of the screening and quantitative assays, has permitted large numbers of donors to be screened quickly and economically, and has helped establish a significant core of regular donors with high TAT levels. The assays have proven to be highly sensitive and specific and relatively simple to perform, while the coated cells are inexpensive and easily prepared. Approximately 20% of donors screened from the Sydney metropolitan area had TAT levels of 3 IU/ml or greater.