Background and Purpose-We sought to evaluate the diagnostic value of echo-enhanced transcranial color-coded duplex sonography (TCCD) and the clinical relevance of vascular pathology assessed by sonography for early clinical outcome in acute ischemic stroke. Methods-We present 23 consecutive patients with an anterior circulation stroke in whom clinical examination, CT, and ultrasonography were performed within 5 hours after the onset of symptoms. Transcranial Doppler sonography (TCD) and unenhanced and contrast-enhanced TCCD (Levovist, 4 g, 300 mg/mL) were compared for their ability to detect middle cerebral artery (MCA) occlusion and flow velocity reduction suggesting hemodynamic impairment in the MCA distribution pathway. Sonographic examination times were registered. Baseline clinical characteristics and CT findings were assessed. Neurological deficit was quantified according to the National Institutes of Health Stroke Scale score, with an early clinical improvement defined as decrease of the score by 4 or more points or a complete resolution of the deficit on day 4. Results-Contrast-enhanced TCCD enabled diagnosis of intracranial vascular pathology in 20 affected hemispheres, whereas unenhanced TCCD and TCD were conclusive in 7 and 14 hemispheres, respectively (Pϭ0.0001). Contrastenhanced TCCD was superior in evaluating distal carotid (carotid-T) occlusion and differentiating major vessel occlusions from patent arteries with flow velocity diminution. Mean examination time for enhanced TCCD ranged from 5 to 7 minutes, depending on the number of investigated vessels (without or with MCA branches). Logistic regression selected a patent MCA without reduced blood flow velocity as the only independent predictor for an early clinical improvement (PϽ0.01). Conclusions-Contrast-enhanced TCCD is a promising tool for early prognosis in anterior circulation stroke. It is considered superior to unenhanced TCCD and TCD. (Stroke. 1998;29:955-962.)
Adrenomedullary hyperplasia (AMH) with increased urinary excretion of epinephrine is regarded as the earliest adrenal manifestation in familial pheochromocytoma; however, pathogenetic mechanisms and morphogenesis involved in the development of sporadic adrenomedullary diseases are unknown as yet. We present 4 patients with clinical, biochemical, imaging, and morphological findings of sporadic unilateral adrenomedullary hyperplasia cured by unilateral adrenalectomy. All patients were hypertensive with intermittent hypertensive crises, and with increased catecholamine concentrations in urine and serum. Correct unilateral localization was achieved by 123-I-BG-scan (planar and SPECT) (n = 2) or cavovenous blood sampling with selective catheterization of both suprarenal veins (n = 2). Histomorphometric analyses revealed diffuse adrenomedullary hyperplasia in all 4 specimens with significant increase of relative volume to 17.6% (controls, 8.7%), and of estimated medullary weight to 0.95 g (controls, 0.45 g); corticomedullary ratio (C:M) was decreased to 5.4 (controls, 11.2). DNA histograms showed euploidy in all cases. In 3 patients, DNA analysis revealed evidence of cell proliferation, but without increase to grade of malignancy indices (0.101-0.523). Adrenalectomy was performed preferentially by a translumbar approach; the operative and postoperative course was uneventful in all 4 patients. Blood pressure without antihypertensive drugs returned to normal in 3 patients, in 1 patient to the upper normal limit.
Paranasal sinuses of 52 patients with sinusitis, tumours or fibrous dysplasia were scanned. Axially acquired spiral data were obtained and reconstructed coronally. Four radiologists compared the two sets of images. They evaluated the diagnostic quality for visualization of the ostiomeatal unit, infundibulum, infraorbital canal, inflammatory disease, fine osseous lamellae and presence of amalgam or step artefacts. Two test phantoms were scanned for both techniques and lens dose was measured. Statistical significant differences in the diagnostic quality of the representation of the fine osseous structures in the paranasal sinuses, attributable to step artefacts were found in the coronally reconstructed images (p < 0.001). However, there was no amalgam and almost no motion artefacts in the reconstructed images. Interobserver correlation was r = 0.953 versus 0.956 for inflammatory disease, r = 0.816 versus 0.852 for artefacts, and r = 0.596 versus 0.547 for fine osseous lamellae in coronally acquired or axially acquired and reconstructed images, respectively. Lens dose was measured between 11.8 mGy and 13.8 mGy for axially acquired and reconstructed images. The advantage of axially acquired, coronally reconstructed images is the absence of artefacts attributable to amalgam and fewer motion artefacts. Axially acquired, coronally reconstructed images are inferior to coronal helical CT images, because of step artefacts, when it comes to evaluating the resolution of fine osseous structures. Nevertheless, reconstructed images are suitable as a investigatory procedure for patients with inflammatory disease who cannot maintain the prone position.
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