DILATED EPISCLERAL ARTERIES/Cow/»ee et al. 45carotid artery occlusion. Dilated episcleral arteries, particularly in the absence of other stigmata of ocular ischemia, strongly suggest that the external carotid artery is the major source of blood supply to the homolateral cerebral hemisphere. Consequently, maintaining patency of the external carotid artery in these situations is important. OVER 50 YEARS AGO, Sydensticker 1 established that sickle cell anemia (SCA) could have prominent neurologic manifestations. A recent review of 89 cases of SCA, proven by electrophoresis to be homozygous for hemoglobin (SS), showed that 29% of the patients had developed neurological complications, and that 17% had had strokes. References2 The patient with SCA we studied arrived in coma as the result of bilateral carotid artery occlusion. Angiography revealed a pattern which is consistent with Moyamoya disease. An autopsy showed thrombosis of major intracranial vessels while intimal hyperplasia, unusual in SCA, was also present. Clinical FeaturesA 7-year-old black boy was admitted to Jackson Memorial Hospital with an acute alteration of consciousness. The patient was originally diagnosed as having sickle cell anemia at the age of 7 months. Originally he had edema of both hands and feet, was anemic, and had a positive sickle cell preparation. Subsequently, he had several hemolytic crises. Seven months before this last admission, the child developed a right hemiparesis with hemianesthesia and Broca's aphasia. This was accompanied by focal myoclonic seizures involving his right arm and the right side of his face. He was given phenytoin and improved, but 4 months later he suffered a similar episode, which left him with moderately severe expressive aphasia. A Tc99 (Technetium) brain scan was diagnostic for occlusion of the left middle cerebral artery. His hemoglobin ranged between 6-8 gm/dl, and his reticulocyte count between 10-40%. Prior to his last admission he had been irritable and was later found comatose. In the emergency room, he was stuporous, and had right spastic hemiparesis, a right gaze preference and right-beating jerk nystagmus. His hemoglobin was 6.9 gm/dl, with a white cell count of 17,400 per mm 3 and 16% reticulocytes. The cerebrospinal fluid contained 11 white blood cells per mm, 8 (45% granulocytes). He was treated with phenobarbital and diazepam and became more alert. Subsequently, an EEG revealed bilateral slowing, more marked on the left. Three days later, he became febrile (102.4°F) and more lethargic. Examination revealed nuchal rigidity and a positive Brudzinski sign. A second spinal tap showed 6850 red cells and 340 white cells per mm 3 with 55% granulocytes and a protein of 322 mg/dl; CSF glucose levels were normal. Cultures of spinal fluid, blood and urine were all negative. A brain scan (Tc99) showed another area of increased uptake in the posterior right hemisphere. The child was treated with penicillin and a transfusion of 1000 ml packed cells after which he improved slightly. Hemoglobin electrophoresis...
Eight macroscopically normal menisci of different ages were obtained at autopsy to study their surface structure. The investigation was carried out using transmission and scanning electron microscopic (TEM, SEM) examinations. The combined methods have not been used before. An understanding of physiologic alterations during age has to be furnished for further research of pathological alterations. The surface relief shows clear differences in different age groups. The meniscus surface of the newborn is built of randomly arranged, equally sized folds and cell formations. The TEM-examination reveals a loose net work of collagen fibrils which is not covered by a membrane-like structure on the joint cavity surface. With age the linear folds become wider extending from the anterior to the posterior segment. They are most prominent in the inner zone; in the middle and outer zone they are flattened at areas of interdigitation. These folds are most likely preparation artefacts rather than closely packed fiber bundles or pathologic osteoarthritic alteration of the surface. This is supported by the TEM examination showing a loose 3-dimensional fiber net work. Early degenerative alterations of the meniscus surface are characterized by a slit-like destruction of this superficial fiber net.
The authors describe two rate cases of extraneural metastases of glioblastoma multiforme and of astrocytoma III-IV, but with different distribution routes. In the first case - astrocytoma III-IV - via the lymphatic system, with metastases in the cervical lymph nodes; in the second case-glioblastoma-via the blood system, with metastases in the sternum and vertebrae. Survival times were 18 months in the astrocytoma case (operation plus irradiation), and 6 months in the glioblastoma case (operation, irradiation, and chemotherapy). The discussion deals with the possible paths of the metastases, the connection between metastatic spread and survival time (in the longer surviving patient the metastases were discovered together with the recurrence), and problems in deciding the individual therapy.
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