Limitations of computed tomography for diagnostic neuroradiology.
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Biomedical subjects
Publications and source records attributed to T Grumme.
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Computed tomography (CT) has given us a new method for examining the orbit and its contents. The technique of examination is described, and the indications for the application of computed tomography in ophthalmology are considered: suspected orbital tumors, unilateral exophthalmos, pareses of the ocular muscles, traumatic lesions and malformations in the region of the orbit. The findings in 210 cases of orbital lesions examined in this study are reported and the differential diagnosis is discussed. Considerable improvement and greater accuracy in diagnosis have been achieved in the field of ophthalmology by using computed tomography. Early tumor visualization is possible without risk or discomfort to the patient.
This paper decribes the results of the CT teams of the University Clinics Berlin, Mainz and Munich. 1658 patients with cerebral tumors have been examined so far (EMI Scanner Mark I, Matrix 160/160) revealing a diagnostic accuracy of 98.4%. The findings of various kinds of tumors (306 glioblastomas, 255 astrocytomas and oligodendrogliomas, 248 meningiomas, 212 metastases, 200 pituitary adenomas and craniopharyngeomas) are discussed and illustrated by typical images. Differential diagnostic problems and the importance of additional neuroradiological procedures are discussed.
One-dimensional echoencephalographic investigations were made of the 3rd ventricle with the Siemens-Krautkrämer Unit USM 1 in 1841 subjects. 200 premature infants with a birth weight of up to 2500 premature infants with a birth weight of up to 2500 g were examined within 48 hours of birth. It was statistically proved, that with increasing weight, advancing gestational age and growth of the head-circumference, the width of the third ventricle diminishes. The material of 1641 children and adults shows the following results: The first phase up to 21/2 years is characterised by a rapid increase in size. The second phase covers the age group up to about the 16th to 20th year and ist characterised by a kind of plateau without significant change in the width of the 3rd ventricle. In the third phase concerning ages from 16 to 20 up to 57 to 58 years, a slow increase to higher values can be observed. The fourth phase, from the 57/58th to 78/79th years, shows a distinctly higher increase than the third phase. Results obtained beyond the 78/79th year were not uniform but rather heterogenous and unpredictable, questioning the concept of a further "physiological" development of the 3rd ventricle. A linear relationship between age and the 3rd ventricle can be demonstrated up to about the end of the 8th decade. Normal values for the 3rd ventricle should not be given in future, without indicating the age.
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The results of transverse axial computerized tomography in EMI scan (transverse CAT) in 2 000 examinations are reviewed. The method was shown to enlarge significantly the diagnostic possibilities in cerebral disease. A correct identification of intracranial tumour was made in 98% of 250 cases. Cerebral haemorrhage, infarction and contusional oedema could be differentiated. Various forms and extensions of cerebral oedema were visualized as never before. Postoperative changes and the course of vascular disease, tumour or hydrocephalus after shunt were demonstrated at an early stage. The indications for pneumo-encephalography have been reduced to a few very special situations. On the other hand, angiography is still of decisive value in vascular cerebral disease and should be performed before surgery in case of space-occupying lesions.
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Computertomography permits an early diagnosis of acute intracerebral hemorrhage a few hours after onset of symptoms. Embolic or thrombotic infarcts may be detected only after 2 to 3 days. Late manifestations of ischemic infarcts are unequivocal when confined to the circulation area of a cerebral artery. They must, however, be differentiated from small gliomas with edema, while in cerebral hemorrhage the differential diagnosis must consider bleeding from tumors and vascular malformations.
CT findings of 46 patients with operatively confirmed chronic subdural hematomas are reviewed. The analysis of the EMI scans resulted in three different types of CT findings. Type 1 is characterized by decreased attenuation of the hematoma contents compared to brain tissue. The hematoma is visualized as a lens-shaped low density area between the skull and the surface of the brain. Type 2 apart from low density areas contains zones of increased attenuation due to recent bleeding into a watery chronic subdural hematoma. In many cases sedimentation causes a well-defined horizontal borderline between the thin fluid parts in the anterior portion and the blood debris in the posterior portion of the hematoma sac. Type 3 shows the same average absorption values as normal brain tissue, a direct visualization is not possible. However , the presence of a midline displacement in combination with ventricular compression and absence of a circumscript lesion even after contrast enhancement, allows the diagnosis of a unilateral chronic subdural hematoma in these cases too. Bilateral chronic subdural hematomas may cause considerable diagnostic difficulties if only one or none of the hematomas is visualized. A relatively small midline displacement points to a second bleeding on the opposite side. Most frequent were hematomas of type 1 (37%), type 2 and 3 could be observed in 30,5% resp. 32,5% of cases respectively.
It is reported how, in 5 cases of arterial haemorrhage, the ligature of an artery was avoided by the use of Heifetz encircling clips with teflon liner. Two of the five patients had aneurysms. The remaining 3 were suffering from brain tumours. Postoperative computer tomography together with neurological follow up examinations indicated, that in two cases there was no disturbance of cerebral circulation. With a carotid angiography it was possible to show that in the other three cases normal flow through the arteries was maintained, 2, 11 and 45 days after emplacement of the clip.
An attempt has been made to show which anatomical structures of the skull and brain can be demonstrated by analysing 668 computerised tomograms of normal brains. Many parts of the bony skull, the cisterns and ventricles and physiological calcification of the pineal body, choroid plexus and falx can be clearly identified. Frequently it is possible to distinguish between grey and white matter in the basal ganglia. After intravenous contrast injection it is sometimes possible to identify arteries and other pathways and vascular structures by their increased contrast. Because of the constant topographic relations in the brain, it is possible to identify these structures with certainty on the computerised tomogram.
The computer tomographic investigation of two epidural and 26 subdural haematomas is described. Various computer tomographic signs are discussed and illustrated by some examples. Measurements of absorption values of subdural haematomas were related to in-vitro experiments.
Princips of computer tomography is demonstrated and the absorption coefficients of ocular and orbital tissue are calculated. The advantages and disadvantages of this procedure are discussed. 39 patients with ocular and orbital diseases were examined by computer tomography. The main indication was tumors, including metastases and diseases arising from ethmoidal cells. Vascular anomalies and tumors were better demonstrated by angiography. Dislocated lens, enlarged tumors of the choroid and prostheses (cerclage and orbital implants) are demonstrable. In contrast to echography, the computer tomography gives certainly better results in the posterior part of the orbit. Technical improvement of the apparatus could lead to a wider use in ophthalmology.
Computertized tomography of the brain, developed by Hounsfield - has decisively altered neuroradiologic procedures. Without the need of contrast media, cerebral structures (ventricles cisternes, sulci and physiological calcifications) and pathologic lesions (infarctions, hemorrhage, edema, tumors and malformations) may be visualized. Tumors can be diagnosed in 95 to 99% by this method. Tumors of the midline structures and of the posterior fossa are more easily detected than by conventional methods. In head injuries epidural and subdural hematoma, contusional edema and hemorrhage may be differentiated. Hydrocephalus externus and internus can be shown by computertized tomography. Probably computertized tomography will become the most frequently applied neuroradiological method in the future.
This report on computerized tomography in 400 children confirms the high diagnostic value of the new method in neuropediatrics. 31 brain tumours were diagnosed in children. Tumors present themselves as lesions of latered density compared to that of brain matter. Intravenous injection of contrast media increases the density of various lesions as tumors, angiomas, acute infarctions and abscess. Infarctions are low density lesions whereas hemorrhage is a high density lesion and both are thus safely differentiated. Edema may be visualized in the vicinity of tumours in brain injuries and in encephalitis. The normal ventricular system, hydrocephalus, cerebral malformations and subdural hygroma are easily demonstrated. Diseases of the orbits may also be detected.
Three hundred eighty-five children were examined with the Midliner echoencephalography unit. In examinations termed adequate, correct interpretations were made in 94.6% of healthy children versus 78% ill children. The incidence of adequate examinations increases with the child's age, but 58% of children with hydrocephalus had inadequate examinations, regardless of age. For the measurement of the infantile ventricle system the midliner is not appropriate.
The examination of the brain with ultrasound has become an indispensible diagnostic tool in all cases of intracranial pathology. Valuable information is obtained both in emergencies and in follow-up studies. Since long practice is necessary before the results of echoencephalograms can be interpreted accurately, a need was felt for a standardization of the examination which would eliminate the subjective influence of the investigator. The automatic midline computer, called Midliner, which has recently become available, makes fewer demands on the experience of the investigator although the diagnostic possibilities are not as broad. The position of the midline echo is of primary interest, although the width of the third ventricle can be successfully determined in occasional cases. this study, which presents the results of the Midliner examinations in three clinics, is grouped according to diagnosis. Through a comparison with conventional A-scan echoencephalograms, as well as with neuroradiological and operative findings in 1889 cases, the reliability of this method is clearly demonstrated. The advantages and disadvantages of the examination are discussed and the field of application indicated.