Biomedical subjects
Publications and source records attributed to C W Kerber.
Two patients with vertebral osteoblastoma evaluated with computed tomography and magnetic resonance imaging are presented. A literature review revealed that cases of osteoblastoma originating within the vertebral body are exceedingly rare.
A 30-year-old male had a headache for one month and was evaluated with both computed tomography (CT) and magnetic resonance (MR). These scans demonstrated an obstructing pineal cyst containing layered acute and subacute blood products by MR criteria. The concurrent scans allowed correlation between CT and MR findings in this rare complication of an unusual entity, explained his headache (and the development of later upward gaze paresis), provided a precise surgical/anatomic approach, and gave a good final clinical result. The report illustrates appropriate CT and MR images and pathological specimen.
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A toxicologic-pathologic study of isobutyl-2-cyanoacrylate (Bucrylate) was carried out first in dogs and then in humans whose arteriovenous malformations were infused with this embolic agent. The canine specimens obtained at 7, 18, 28, and 147 days after embolization showed the development of a mild histiocytic giant cell reaction, which evolved to end-state sclerotic arteritis. The response was confined to the vessels and did not involve contiguous parenchymal tissues. Ten human specimens, obtained from 1 hr to 7 years after treatment, showed a similar bland reaction with no evidence of suppuration or premalignant changes.
Perineurial arachnoid cysts are often multiple lesions that are usually found in the lumbosacral area. These cysts may cause compression of surrounding structures. Examination of the first, second and third sacral nerves should be performed on patients with prolonged symptoms of a herniated disc or cauda equina syndrome. Three cases are presented for which computed tomography provided accurate, noninvasive diagnosis. Perineurial cysts are often associated with asymptomatic herniated disc; thus, surgery on the disc with an underlying symptomatic cyst may result in a failed back syndrome.
Fracture of the inferior lumbar articular facets after laminectomy with facetectomy is a relatively common but unrecognized cause of radiculopathy. Although not all patients may be symptomatic from the fractures, some may have radiculopathy or back pain caused by displacement of the fracture fragment. In a series of 400 postoperative spinal computed tomographic (CT) scans, 25 patients were found who had fractures through the base of the inferior facets. Axial scans revealed no abnormality other than slight widening of the joint on the affected side. Sagittal views demonstrated a lucent defect similar to a pars interarticularis fracture, whereas coronal views showed the fracture at a different location in the base of the facet. Typically patients become symptomatic after a period of postsurgical well-being. A new pain pattern, local tenderness, pain on unusual movements, and relief with recumbency help suggest facet fracture versus recurrent disk herniation.
Using our modification of the vein patch technique, we created 16 aneurysms in the common carotid arteries of dogs. After a stabilizing and healing period, these aneurysms were treated using percutaneous catheter techniques. Coaxial microcatheters were placed into the aneurysms, and a mixture of isobutyl 2-cyanoacrylate and tantalum dust was infused through the microcatheter using real time fluoroscopic control. Fifteen of the 16 aneurysms were successfully occluded; 1 was a failure because of total occlusion of the carotid artery. One human facial artery aneurysm was similarly treated. The ease and technical details of the treatment are discussed. Although the results are encouraging, we believe that it would be prudent to broaden the animal experimentation rather than to begin human use. Because no experimental aneurysm models are yet physiological, our results must be applied with caution to human intracranial aneurysms.
This communication presents our experience with eight patients who were initially evaluated as having normal cerebral computed tomographic (CT) scans. Follow-up scans ranging from 2 to 9 months later showed interval appearance of large contrast enhancing mass producing lesions. All eight of these patients turned out to have glioblastoma multiforme. This phenomenon of "false-negative" CT does not seem to be dependent on the type of equipment used or the age of the patient. Negative CT should not dissuade radiologists and clinicians from believing that a patient with appropriate symptoms and signs does indeed harbor a brain tumor.
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Our diagnostic and therapeutic approach to arteriovenous malformation is based on the available knowledge of the hemodynamics of these lesions. Four cases are presented. One demonstrates the deleterious effects of proximal vessel ligation. Two cases are treated with flow-controlled embolization, wide excision, and axial flap coverage of the defect with no recurrence on physical examination at more than 2 years. The final case illustrates a relatively small arteriovenous malformation that replaced one-half of the lower lip and chin. An extensive resection is done and the defect is reconstructed with an innervated and well-vascularized neck flap.
From November 1976 to September 1979, 46 patients with intracranial arteriovenous malformations or fistulas participated in a clinical study using isobutyl 2-cyanoacrylate (IBCA), with tantalum, for palliative or preoperative occlusion of the blood supply to the abnormalities. Although failure to obtain satisfactory position of a functioning microcatheter precluded deposition of IBCA 10 times, a total of 51 of a possible 62 feeding vessels were occluded with the tantalum-impregnated glue. The technique, results, and complications are discussed in light of the clinical follow-up, which varied from 12 to 48 months.
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A feared complication of therapeutic embolization is loss of control of one or more particles with resultant ischemic infarction of normal tissues. To avoid passage of emboli into normal arteries, the delivery catheter may be wedged tightly into the artery or the artery completely occluded with a balloon catheter during embolus injection. These techniques, termed occlusion control, were a valuable forward step and significantly enhanced patient safety. However, occluding the vessel completely may cause spasm, and allows the operator to introduce fluid and emboli under higher than normal perfusion pressures which can open extra- to intracranial shunts and cause disastrous intracranial embolization. A further refinement is suggested. First, the emboli are suspended in contrast agent; then the particles are introduced while arterial runoff of the contrast agent is watched so the acceptance rate of the artery is not exceeded. Normal perfusion pressures and flow then carry the embolus distally into the abnormality being treated. This technique is safe, easily learned, and gives the radiologist direct vision control over the embolization process. It has been used in39 patients with only one serious complication.
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Lorazepam is of value in the performance of gas encephalography. Given with judicious and individualized doses of IV narcotic, it has significantly lessened the morbidity of this examination. We have been particularly impressed with the lack of unpleasant memories for the procedure. The quality of the examination was good through the patients had to be reminded, because of the amnestic effects of the drug, to hold still throughout the 6-s exposure needed for polytomography.
Iatrogenic neurological deficit constitutes the greatest risk during therapeutic embolization in the vascular territories of the carotid and vertebral arteries. Constant monitoring of the patient's neurological status is therefore essential. The authors discuss the use of medical hypnosis to circumvent general anesthesia and to reduce chemical sedation to a minimum. Their experience with this technique is presented.
We report a new treatment for carotid-cavernous fistula. Using a flow-guided, balloon-tipped microcatheter, we catheterize the fistula itself, verify balloon entry into the fistula with fluoroscopy and x-ray films, and then infuse the tissue adhesive isobutyl-2-cyanoacrylate with careful fluoroscopic control. Three patients have had their fistulas occluded, with preservation of flow through the internal carotid artery. This balloon microcatheter allows the radiologist to perform a reversible test occlusion. All three patients had neurological changes during or after the procedure, and in one we inadvertently occluded several distal middle cerebral artery branches without permanent neurological deficit. No patient became blind or developed 3rd, 4th, or 6th nerve palsy from the treatment. This technique seems to have promise as another method for the obliteration of carotid-cavernous fistula.