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OBJECT: In this retrospective study conducted at Atkinson Morley's Hospital and Middlesbrough General Hospital, the authors analyzed 100 matched patients who had suffered subarachnoid hemorrhage (SAH) to determine whether the technical procedure by which aneurysms are treated affects the development of chronic hydrocephalus. METHODS: Four hundred seventy-five patients presented with SAH between 1995 and 1998. Exclusion criteria included posterior circulation aneurysms, multiple aneurysms, electively clipped or embolized aneurysms, angiographically undetected SAH, patients who died within 1 month of neurosurgical intervention, and patients with the same aneurysm location but a different Fisher grade. The authors matched 50 patients who underwent embolization of their aneurysms with another 50 who had similar Fisher grades and aneurysm types and underwent clipping of their aneurysms. The maximum incidence of ruptured aneurysms occurred in patients who were between 41 and 60 years of age, with women preponderant in both study groups. In each group, 27 patients had anterior communicating artery aneurysm, 13 had posterior communicating artery aneurysm, seven had middle cerebral artery aneurysm, and three had internal carotid artery aneurysm. The lesions in three patients in each group were Fisher Grade I, in 23 patients they were Fisher Grade II, in 14 they were Fisher Grade III, and 10 patients had Fisher Grade IV SAH. Nine patients among those with clipped aneurysms and eight of the patients who underwent embolization had hydrocephalus for which they needed intervention. These interventions included lumbar puncture, ventricular drainage, and ventriculoperitoneal (VP) shunt placement; three patients in each group needed VP shunt placement. CONCLUSIONS: The technical procedure used to treat aneurysms, whether clipping or embolization, does not significantly affect the development of chronic hydrocephalus. However, a larger sample of patients is needed for accurate comparisons and stronger conclusions.

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Cranial ultrasound is currently the primary imaging modality employed in the assessment of the neonatal brain. Due to recent technological advances it is now possible to examine the developing cerebral surface, to assess sulcal-gyral maturation, and to investigate subtle changes in cerebral blood flow and parenchymal perfusion. This review discusses the currently accepted and the more controversial indications for neonatal transcranial ultrasound.

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BACKGROUND: Increased frequency of coronary heart disease in familial hypercholesterolaemia is well documented but the association with carotid atherosclerosis is less well established. The ultrasound appearances of the carotid arteries in familial hypercholesterolaemia patients without symptomatic cerebrovascular disease were therefore investigated. METHODS: 59 patients (34 men, 25 women; mean age 46.6 (+/-12.1 years) were prospectively studied using ultrasound examination of the extracranial carotid vessels. Intimal-medial thickness was measured 1 cm proximal to the carotid bulb and morphology of plaque was classified as heterogeneous or homogeneous according to echogenicity. RESULTS: 44 (75.0%) of the patients had carotid artery disease. On stepwise logistic regression, significant predictors of the presence of carotid artery disease were age (P = 0.014), serum triglycerides at time of examination (P = 0.013), coexistent coronary heart disease (P = 0.03) and the cholesterol-years score (CYS) (P = 0.015). Heterogeneous carotid plaque was associated with a higher plasma level of Lp(a) (P = 0.035), TG (P = 0.024), CYS (P = 0.0003) and the presence of CHD (P = 0.001). Matched pairs (n = 22) of patients, where the only variable was Lp(a), showed a marked increase in heterogeneous plaque frequency in those with high Lp(a) levels (P < 0.03). CONCLUSION: Asymptomatic carotid artery disease occurs in a high proportion of familial hypercholesterolaemia patients. The presence of heterogeneous carotid plaque is significantly associated with the presence of coronary heart disease, the calculated cholesterol-years score, hypertriglyceridaemia and raised levels of Lp(a).

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Embolization is increasingly used to treat systemic arteriovenous (AV) shunts although its success, as judged by either angiographic or clinical means, is difficult to quantify. The aim of the study was to quantify blood flow through AV shunts with 133Xe, which, because of its relatively long transit time through peripheral tissues, behaves like microspheres. Following arterial injection, 133Xe entering an AV shunt rapidly arrives in the lung and can be quantified with a scintillation probe. In 17 patients with systemic AV shunts, the reduction in shunt flow following therapeutic embolization was quantified in the angiography theatre by comparing the initial count rates in the lung, recorded by probe, following injection of identical quantities of 133Xe into a supplying artery before and after embolization. By comparing the lung counts with those given by an intravenous injection of 133Xe, the fraction of flow at the catheter tip entering the shunt was also quantified. Tissue perfusion in the vascular territory distal to the shunt was measured at the same time by recording the clearance of non-shunted 133Xe with a second probe over the extremity. Control injections of 133Xe were given in the contralateral limb in order to assess 133Xe transit in the absence of shunting and to compare tissue perfusion between the two sides. Shunt flow ranged from 40% to 100% (of that at the tip of the catheter) (n = 14), while the reduction in shunt flow following embolization ranged from 15% to 96% (n = 19). Tissue perfusion distal to the shunt and in the contralateral limb was about 5 ml 100 ml-1 min-1. Contrast medium had no consistent effect on tissue perfusion in either limb, or on shunt flow. There was no difference in peripheral perfusion between the abnormal and control sides, nor any significant difference in perfusion in the distal tissue on the abnormal side before and after embolization. There was, however, a consistent increase in the fraction of the injected 133Xe delivered to the distal tissue after embolization (median increase 93%, p < 0.001). The technique is relatively simple and merits further development as a means of continuous quantification of systemic AV shunt flow in the angiography theatre at the time of embolization.

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The effect of spinal degenerative changes and aortic calcification on bone mineral density measurements was studied in 115 healthy early post-menopausal women. Lateral lumbar spine radiographs and quantitative computer tomography images were used to determine the presence and severity of aortic calcification and degenerative changes in the lumbar spine. Women with spinal degenerative calcification had higher spine bone density when measured by dual photon absorptiometry compared to those without calcification (P < 0.01), but this was not reflected by the quantitative computer tomography or the proximal femur bone densities, suggesting that spinal calcification artefactually increases spinal bone density when measured by dual photon techniques. Women with aortic calcification had significantly lower quantitative computer tomography and proximal femur bone density compared to those without calcification (both P < 0.05). These women may be at increased risk for both osteoporosis and cardiovascular disease, suggesting a common aetiological factor such as oestrogen deficiency.

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In fibrosing alveolitis the pattern type on thin section computed tomography (CT) predicts histological appearances at open lung biopsy and the likelihood of response to treatment. To test the level of inter- and intra-observer variability on CT and chest radiography (CXR), the pattern type and extent of disease were assessed by four observers (two experienced, two inexperienced). A total of 126 CT examinations and 108 concurrent postero-anterior chest radiographs were scored on two occasions, at least 8 weeks apart. A confidence rating was assigned to each observation. Three out of four observers agreed on pattern type in 81% of cases on CT compared with 54% on CXR (kappa coefficient 0.48 and 0.16 for CT and CXR, respectively). Inter-observer variability in categorizing pattern type on CT was lowest in patients with the highest confidence scores (kappa = 0.63). Confident observations were associated with extensive or moderately extensive disease (P < 0.001), and with a predominantly reticular pattern (P < 0.0001). Intra-observer variability for pattern type on CT was less for the experienced observers (kappa = 0.78 and 0.70) than for the inexperienced group (kappa = 0.50 and 0.37). Inter-observer variability for extent of disease was significantly less on CT than on CXR (standard deviations 7.8% and 9.2% respectively, P < 0.001). This study shows that observer variability using a clinical grading system is lower with CT than with chest radiography in fibrosing alveolitis.

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Granulosa theca cell tumours represent the largest group of hormone-secreting ovarian tumours and comprise approximately 1.5% of all ovarian malignancy. However, the prognosis and behaviour of pure granulosa cell tumours have been particularly difficult to evaluate, because in previous reports they have been grouped with granulosa theca cell tumours. Consequently, their radiological features and the possible contribution of computed tomography (CT) to clinical management has not been evaluated. We report the CT appearances of 15 patients with pure granulosa cell tumours and their clinical outcome. The results suggest the possibility of a positive relationship between histological grade and FIGO stage at presentation. Large tumour volume, extensive lymph node involvement and ascites on CT are adverse prognostic features. However, patients with abdominal masses less than 9 cm in diameter, absent or small volume lymph node disease and peritoneal and liver metastases achieved complete remission, suggesting that CT can assist in identifying those patients likely to respond best to current therapeutic regimens.

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Radiolabelled serum amyloid P component scintigraphy provides information on the diagnosis and distribution of amyloid which was not previously available. A simple reproducible method for quantifying the uptake of 123I-labelled serum amyloid P component into individual livers, spleens and kidneys was devised and evaluated in 22 patients with different types of systemic amyloidosis. Prospective studies in 10 patients were undertaken in order to monitor aspects of the natural history of visceral amyloid deposits. Although measurements of tracer uptake were not as discriminating for diagnostic purposes as the opinions of two highly experienced visual observers, the availability of objective scintigraphic parameters should facilitate interpretation of serum amyloid P component scans in centres unfamiliar with the technique. The follow-up studies demonstrated several intriguing features of amyloidogenesis. There was very rapid progression of deposits in some individuals with differential rates of accretion in different organs. The single patient with AL amyloidosis treated with cytotoxic drugs showed substantial regression of hepatic amyloid deposits whilst his splenic amyloid increased. His spleen was then removed and further regression of the hepatic amyloid was observed. It is concluded that quantitative serum amyloid P component scintigraphy is a useful method for assessing visceral amyloid and that the deposits not only progress at extremely variable rates, but can evidently also be mobilized. These findings encourage active therapeutic approaches in the management of amyloidosis.

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Pyrexia of unknown origin (PUO), the commonest cause of which is occult infection, represents a difficult diagnostic problem. Radiolabelled white cell scanning provides a non-invasive and potentially useful diagnostic tool in this condition, but its efficacy remains controversial. In a retrospective study, we analysed 30 111In white cell scans, performed between 1983 and 1988 in 25 patients with PUO, strictly defined as a fever of at least 3 weeks duration reaching 38.3 degrees C on more than three occasions and investigated in hospital for a minimum of 7 days. Eleven studies were on post-operative patients who, although developing fever within 1 week of surgery, satisfied the above criteria. Overall, the diagnostic sensitivity and specificity were 55% and 74% respectively, with an overall accuracy of 67%. This improved to 91% in the post-operative patients compared to an accuracy of 52% in spontaneous PUO. Accuracy did not correlate with duration of symptoms, leucocytosis or index of clinical suspicion. In conclusion, although 111In white cell scanning is not particularly useful for the investigation of spontaneous PUO, it does have a role in post-operative PUO.

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The value of serial measurements of heel pad thickness as a clinical predictor of biochemical remission in acromegaly was assessed in 25 patients followed for up to 20 years after treatment by interstitial irradiation using yttrium-90 implantation. Growth hormone (GH) levels fell to 50% of baseline values within 12 months of therapy (P less than 0.001) and to 21% at 5 years, reaching normal levels after 10 years, constituting a biochemical cure maintained to the end of the study period. By contrast, heel pad thickness remained relatively stable, falling to 95% of baseline after 5 years (P less than 0.05) and to 87% after 20 years. There was no overall correlation between the measured parameters (r = 0.033, P greater than 0.05) suggesting that heel pad thickness is a poor predictor of biochemical remission in acromegaly.

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A patient with a subcarinal bronchogenic cyst is described. The cyst was aspirated using an extrapleural percutaneous approach under CT guidance, employing repeated injections of 4-5 ml of saline to split the parietal pleura from the chest wall. Thus we describe a technique that allows the insertion of a catheter into a cyst and complete evacuation of its contents.

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A 61-year-old man ingested a large amount of carbon tetrachloride, well in excess of the adult lethal dose. The level of the compound was assayed in his blood and the levels were the highest ever recorded by the Guy's Hospital Poisons Unit. He was treated by intravenous infusion of acetylcysteine and survived with relatively mild clinical and biochemical evidence of toxicity. Possible reasons for his survival are discussed, as are the implications for the management of future cases.

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