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Although the pathologic substrate of Tourette's syndrome (TS) is unknown, studies have implicated subtle changes in the basal ganglia. To further investigate structural basal ganglia pathology in TS, we performed morphometric analyses of MRIs of 10 monozygotic twin pairs discordant for severity of TS but concordant for the presence of tic disorders (mean age, 16.3 years; range, 9 to 31 years). Right caudate volume was slightly but significantly reduced in the relatively more severely affected twins as a group compared with the less affected twins (mean difference = 6%, p < 0.01). Most of this difference was attributable to volume reduction in the anterior right caudate (p < 0.02), which was smaller in the more severely affected twin in nine of 10 twin sets. The mean volume of the left lateral ventricle was 16% smaller in the more severely affected twins than in the less severely affected twins (p < 0.01). The normal asymmetry of the lateral ventricles (left greater than right) was not present in the more severely affected twins, who had a trend toward a larger right lateral ventricle. Moreover, the difference within a pair in the degree of loss of the normal ventricular asymmetry correlated with the difference within a pair in the severity of the tic disorder (r = 0.75, p < 0.02). There were no other basal ganglia, ventricular volumetric, or asymmetry abnormalities. These findings partially replicate other MRI studies and suggest that subtle structural abnormalities in the CNS, particularly in the caudate, may play a role in the pathophysiology of TS.(ABSTRACT TRUNCATED AT 250 WORDS)

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A young man with headache was unable to sneeze despite a strong sensory urge to do so. Magnetic resonance imaging revealed a cystic neoplasm in the medulla oblongata that presumably interrupted the efferent arc of the sneezing reflex.

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To investigate evidence for diffuse white matter injury and hemispheric disconnection sequelae after severe closed head injury (CHI), this study evaluates the degree of posttraumatic atrophy of the corpus callosum. Corpus callosal atrophy was quantitatively determined using a digitizer to measure sagittal magnetic resonance images of 32 patients with moderate-to-severe CHI and those of 31 control subjects of similar age. In the CHI patients, measurements were significantly reduced for the areas of the anterior four-fifths, the posterior one-fifth, and the total corpus callosum. Moreover, the minimum width of the callosal body was reduced in the CHI patients as compared to that of control individuals. Indices of corpus callosal atrophy were significantly correlated with the chronicity of injury and the degree of lateral ventricular enlargement. There was no difference in callosal measurements between men and women. Magnetic resonance imaging provides an in vivo determination of corpus callosal atrophy which may reflect the severity of diffuse axonal injury and predict the type and severity of hemispheric disconnection effects.

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Magnetic resonance (MR) imaging was performed in 94 patients who sustained closed head injury of varying severity. Results of MR studies obtained after the intensive care phase of treatment disclosed that intracranial lesions were present in about 88% of the patients. Consistent with the centripetal model of progressive brain injury proposed in 1974 by Ommaya and Gennarelli, the depth of brain lesion was positively related to the degree and duration of impaired consciousness. Further analysis indicated that the relationship between depth of brain lesion and impaired consciousness could not be attributed to secondary effects of raised intracranial pressure or to the size of intracranial lesion(s).

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The diagnosis of diffuse brain injury is considered when computed tomography provides no evidence of an intracranial mass lesion in acute nonmissile head injury. Magnetic resonance imaging (MRI) of a young woman who had sustained severe diffuse brain injury five years earlier disclosed multifocal lesions involving the frontal, temporal, parietal, and occipital lobes. We report the results of serial neurobehavioral assessment for clinical correlation with the brain lesions visualized by MRI. Pending confirmation of our findings in a series of patients studied by MRI during the acute and chronic stages of recovery from head injury, we postulate that the presence and type of neurobehavioral sequelae of diffuse brain injury are related to the intrahemispheric loci of predominantly white matter lesions and degeneration.

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One hundred cranial computed tomograms of adults with known or suspected intracranial neoplasm were analyzed retrospectively. Rapid high-dose intravenous contrast infusion (84.6 g l) was followed by immediate and 1 1/2-hour delayed scans. Delayed images afforded more information than the initial series in 67% of cases. 11.5% false-negative examinations (i.e., no tumor reported) would have resulted if studies were terminated after the immediate post-infusion scans. No patient experienced clinically detectable renal compromise.

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An unusual isodense acute subdural hematoma is reported. Its causes may have included dilution with cerebrospinal fluid and a local or disseminated coagulopathy. Detection of such lesions requires a high incidence of suspicion based on subtle abnormalities found on computed tomography and the use of enhancement, particularly with the aid of advanced scanners. When a significant shift of the midline is seen, other alternatives would be angiography or placement of an exploratory burr hole on the "swollen" side.

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A patient is reported who during vigorous back bleeding after unclamping of the internal carotid artery during endarterectomy had EEG slowing and a postoperative increase in neurological deficit. This phenomenon, an apparent steal, has not been reported and suggests that EEG monitoring is as vital at unclamping as it is after clamping. The patient also raises questions about the risk of early endarterectomy for those who have persistent deficits, even with unobstructed vessels.

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A delayed traumatic intracerebral hematoma was seen in a patient after a shotgun wound to the brain. The cause of the hemorrhage seemed to be a traumatic aneurysm. Both complications are reviewed, and it is suggested that clinical and intracranial pressure monitoring should lead to early diagnosis and may minimize the effects of this problem and that angiography may be appropriate early in the course of patients who have had fragments pass near intracranial vessels.

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Five cases of subdural empyema are described. Two of the cases eluded a definitive computed tomography (CT) diagnosis despite classical clinical background. Extracerebral collection with definitive border enhancement was seen in the other three cases. Mass effect, present in all five cases, was related to the extracerebral collection in three cases and diffuse cerebral edema and/or infarction in two. Angiography in four cases initially demonstrated an extracerebral collection in three and inflammatory angiospasm in two. Repeat angiography demonstrated an extracerebral collection in the fourth case. In the proper clinical setting subdural empyema should be considered even in the absence of an extracerebral collection when mass effect or an infarction pattern is seen on CT. Angiography may be diagnostic in such cases. Hopefully, newer techniques will further the diagnostic efficacy of CT in this disease.

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Use of therapeutic arterial embolization (TAE) in the traumatized patient can achieve rapid control of hemorrhage and obviate the need for immediate surgery on poor-risk patients or in high-risk areas of the body. The techniques of embolization, its risks, and complications are discussed in light of the authors' experience, and a review of recent literature is presented.

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Arterial embolization was performed in nine patients with metastases from renal carcinoma who had severe pain resistant to conventional therapy. Patients with metastases in the ilium (four), the lumbosacral spine (one), and the base of the skull (one) experienced pain relief lasting from one to six months. The other three patients, who had metastases in the proximal femur, underwent preoperative embolization to facilitate tumor curettage and internal hip fixation. No significant complications were seen with this therapeutic approach.

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A preliminary retrospective correlation between computed tomographic scans and intracranial pressure (ICP) monitored was performed for 21 patients. No patient with a normal CT scan had elevated ICP. The lowest correlation was noted with slit ventricles; the highest, with dilatation of the contralateral temporal horn.

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A prototype computed radiography (CR) system was evaluated for its efficacy as an independent diagnostic modality. Preliminary measurements of high contrast resolution, low contrast perceptibility, and dose were obtained. Clinical examinations including skull, abdomen, liver, gallbladder, biliary system, spine, and extremities were performed as an adjunct to either computed tomography or CR. The data suggest that CR can be an effective diagnostic imaging modality by itself. Advantages over conventional radiography include high scatter rejection, low patient dose, wide dynamic range, and good low contrast sensitivity for large objects; disadvantages, its long exposure time and relatively poor high contrast spatial resolution.

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Rhabdomyosarcoma of the head and neck may be treated with surgery, radiotherapy and chemotherapy or a combination thereof. Precise delineation of the full extent of the tumor in the head and neck is essential. Routine radiographs with hypocycloidal tomography and CT are complementary in defining the full extent of the lesion. Tomography is superior to CT scanning in demonstrating fine bone detail. Demonstration of the soft tissue tumor and its extensions is better seen on CT. The ability to discriminate differences more accurately in densities allows computerized tomography to appreciate better the integrity of the bone margins such as the thin walls of the sinuses.

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