1/35. endoscopy of the spinal cord: cadaveric study and clinical experience.Recent improvements in instruments permit endoscopic examination of previously inaccessible sites. We report on the clinical use of a small-diameter endoscope to examine the spinal subarachnoid space, cord surface and syrinx cavities. Prior to clinical application, three types of endoscopes with external diameters of 0.5, 1.4 or 2.2 mm were inserted percutaneously in the lumbar region of five cadavers for preclinical evaluation of the procedure and the three endoscopes. The observations permitted us to perform spinal endoscopy preoperatively or intraoperatively using the 0.5-mm instrument in seven patients with spinal cord lesions between 1995 and 1997. The patients included two with spinal cord herniation through a dural defect, two with syringomyelia, one with spinal arachnoid cyst, one with spinal epidural cyst and one undergoing lumboperitoneal shunt for hydrocephalus. In patients in whom an endoscope was used preoperatively, the endoscope provided morphological information useful in preoperative diagnosis and planning surgical strategy. When the endoscope was used intraoperatively, areas outside the field of vision of a microscope could be examined, and physiological evaluation could include visualizing improved cord perfusion from the spinal subarachnoid space after surgery. endoscopes could be safely inserted and approached to the lesions under direct vision while avoiding blood vessels and nerve roots on the spinal cord surface. No changes in symptoms or complications occurred in association with endoscopy. Using a small-diameter endoscope, the contents of the spinal subarachnoid space could be examined. Further improvements to increase possible endoscopic manipulation and enhance safety may extend the possibilities for endoscopic examination and permit endoscopic treatment.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
2/35. Progressive necrotic myelopathy: clinical course in 9 patients.OBJECTIVE: To review the clinical, laboratory, and radiological findings of 9 patients who had progressive idiopathic myelopathy with evidence of spinal cord necrosis. DESIGN AND methods: We reviewed personally examined cases of myelopathy that fulfilled the following criteria: (1) regional loss of reflexes, flaccidity, and muscle atrophy; (2) magnetic resonance imaging showing a shrunken or cavitated cord without evidence of arteriovenous malformation; (3) electromyogram showing denervation over several contiguous spinal cord sgements with preservation of sensory potentials in some cases; and (4) the absence of evidence of systemic disease or neoplasm. RESULTS: The illness began in these patients after the age of 40 years, with prominent burning or tingling limb pain, occasionally with radicular features or with less well-defined back, neck, or abdominal pain. Leg or infrequently arm weakness appeared concurrently or soon after the onset of pain. The most distinctive feature was a saltatory progression of symptoms, punctuated by both acute and subacute worsenings approximately every 3 to 9 months, culminating in paraplegia or tetraplegia. The distinguishing clinical findings, together indicative of destruction of gray matter elements of the cord, were limb atrophy, persistent areflexia, and flaccidity. The concentration of cerebrospinal fluid protein was typically elevated between 500 g/L and 1000 g/L, without oligoclonal bands, accompanied infrequently by pleocytosis. magnetic resonance imaging showed features suggesting cord necrosis, specifically swelling, T2-weighted hyperintensity, and gadolinium enhancement over several spinal cord segments, succeeded months later by atrophy in the same regions. necrosis of the cord was found in biopsy material from one patient and postmortem pathology in another case, but inflammation and blood vessel abnormalities were absent. Only 2 patients had prolonged visual evoked responses. The disease progressed despite immune-modulating treatments although several patients had brief epochs of limited improvement. CONCLUSIONS: The saltatory course, prolonged visual evoked responses in 2 patients, and a cranial abnormality on magnetic resonance imaging in another, raised the possibility of a link to multiple sclerosis. However, the normal cranial magnetic resonance imaging scans in 6 other patients, uniformly absent oligoclonal bands, and poor response to treatment were atypical for multiple sclerosis. On the basis of shared clinical and laboratory features, idiopathic progressive necrotic myelopathy is indistinguishable from a limited form of Devic disease.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
3/35. Bilateral blindness and lumbosacral myelopathy associated with high-dose carmustine and cisplatin therapy.PURPOSE: To report the early ocular pathologic findings associated with high-dose carmustine and cisplatin therapy. methods: A patient with metastatic breast carcinoma developed an acute onset of branch retinal artery occlusion, bilateral blindness, and a myelopathy involving the lower extremities after high-dose chemotherapy and bone marrow transplant. RESULTS: Histopathologic examination of the eye and optic nerves at autopsy disclosed nerve fiber layer infarction secondary to right inferior temporal retinal artery thrombosis. Patchy necrosis of both optic nerves, medulla oblongata, and spinal cord was associated with focal small-vessel thrombosis. CONCLUSIONS: The syndrome of retinal vascular occlusion, optic neuropathy, and myelopathy is associated with the high-dose chemotherapeutic agents carmustine and cisplatin. The distribution of necrosis suggests an ischemic event rather than direct neurotoxic effects.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
4/35. February 2001: A 74 year old man with a history over 3 months of increasing dyspnea and malaise.The February COM: A man of 78 years with idiopathic late-onset cerebellar ataxia developed renal failure in association with a high ESR and positive pANCA. This was complicated by a subclinical spinal subarachnoid hemorrhage which was related to necrotizing inflammation of small leptomeningeal vessels. Renal cortical infarcts were due to similar inflammation in arcuate and interlobular arteries. Spinal subarachnoid hemorrhage is rare and usually due to rupture of an arteriovenous malformation. However, an immunogenic connective tissue disorder should be considered in the differential diagnosis. In this case, the histology and results of an autoantibody screen support a diagnosis of microscopic polyangiitis.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
5/35. Evaluation of spontaneous intracranial hypotension: assessment on ICP monitoring and radiological imaging.We describe two recent cases of spontaneous intracranial hypotension. A 38-year-old woman developed a severe postural headache. magnetic resonance imaging (MRI) showed marked dural enhancement. Histopathological findings of dural biopsy showed numerous dilated vessels in the dura, rather than hypertrophic change. Lumber CSF pressure was 5 cmH2O and RI cisternography suggested CSF leakage. A 58-year-old woman with postural headache and vertigo had bilateral subdural haematoma associated with diffuse dural enhancement on MRI. Lumber CSF monitoring confirmed persistent low pressure ranging from 0-5 cm H2O. MRI myelography revealed multiple CSF pouches along the whole spinal axis. CSF leakage was demonstrated on Radioisotope (RI) cisternography. Both cases described in this report were diagnosed as spontaneous intracranial hypotension caused by CSF leakage from spinal meningeal diverticula and were successfully treated by intravenous factor xiii administration.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
6/35. Intramedullary cysticercosis. Case report, literature review and comments on pathogenesis.A 60-year-old woman developed progressive spastic crural paraplegia and global anesthesia and global anesthesia below T10, succumbing to urinary infection and bronchopneumonia 8 months after the onset of symptoms. At necropsy, the spinal cord was completely destroyed by a necrotic intramedullary cysticercus at T8. Six cysticerci were found in the brain. A review of the 17 published cases of intramedullary cysticercosis (including this one) showed this condition to be clinically indistinguishable from spinal cord tumours. The surgical prognosis was fair in 8 of 11 operated patients. The role of hematogenous and ventriculo-ependymal pathways in the pathogenesis of intramedullary cysticercosis was examined. The topographical distribution of intramedullary cysticerci (5 cervical, 12 thoracic, 2 lumbar, none sacral) was found to be statistically proportional to the blood flow to each of these regions; this favours the hematogenous route of infestation. The low spinal cord blood flow (100 times less than that to the brain), the type of vascularization of the cord (low calibre vessels under low pressure) and peculiarities of the cord tissue (such as its harder consistency) are all thought to be contributory factors accounting for the scarcity of intramedullary cysticerci. No evidence for an ependymal route of spread could be adduced.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
7/35. The neurological masquerade of intravascular lymphomatosis.BACKGROUND: Intravascular lymphomatosis (IVL) is an uncommon systemic disease characterized by occlusion of small vessels by malignant lymphomatous cells. central nervous system involvement usually presents as subacute encephalopathy, dementia, seizures, or multifocal cerebrovascular events. OBJECTIVE: To increase awareness about IVL, an uncommon cause of neurological disease. DESIGN: This is a retrospective case series of 8 pathologically proved cases of IVL with neurological disease. patients were part of a pathological series collected between April 1962 and October 1998 at indiana University School of medicine and the Armed Forces Institute of pathology, washington, DC. SETTING: Neurological and neuropathological examinations were performed at tertiary referral hospitals. patients: Eleven patients were diagnosed pathologically as having IVL, but 3 were not included in this evaluation because of a lack of appropriate clinical information. Of the final sample (n = 8), there were 4 men and 4 women (mean /- SD age, 62.9 /- 9.9 years). RESULTS: All 8 patients had focal neurological deficits, 7 had encephalopathy or dementia, 5 had epileptic seizures, and 2 had myelopathy. death occurred at a mean of 7.7 months (range, 1-24 months) after the onset of symptoms. All patients had elevated cerebrospinal fluid protein levels, 4 had pleocytosis, and 2 had an elevated IgG level in their cerebrospinal fluid. Of the 4 patients who underwent a brain biopsy, 1 was diagnosed as having IVL before death. CONCLUSIONS: Intravascular lymphomatosis is an uncommon disease with a myriad of potential neurological manifestations. diagnosis requires a high index of suspicion and a pathological examination. If diagnosed early, aggressive chemotherapy is potentially curative, although the overall prognosis remains dismal.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
8/35. Myelopathy from intracranial dural arteriovenous fistula.Dural arteriovenous fistulas arising intracranially are an uncommon cause of progressive myelopathy. This report is of a patient in whom the diagnosis of the condition was confounded by coexisting small vessel cerebrovascular disease.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
9/35. Myelopathy and sciatica induced by an extradural S1 root haemangioblastoma.Haemangioblastomas are vascular tumours which mainly involve the central nervous system and retina, often in the setting of von hippel-lindau disease. Haemangioblastomas occurring outside the central nervous system are uncommon. Wherever it is, recognising this tumour prior to surgery is desirable, as preoperative embolisation may be considered. We report the clinical, imaging and pathological features of a sporadic sacral root haemangioblastoma in a 58-year-old man with chronic sciatica and myelopathy. The diagnosis was questioned preoperatively because an enlarged sacral foramen, seen to be filled by a highly vascular, enhancing mass and dilated vessels. Myelopathy was attributed to the presumed high venous pressure resulting from increased flow in veins draining the vascular tumour. Microneurosurgical excision was performed after endovascular embolisation and led to persistent clinical improvement.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
10/35. Observations on radiation myelopathy.Three cases of radiation myelopathy are reported. Corticosteroid therapy was associated with worth-while remissions in 2 patients. Two patients showed swelling of the spinal cord in myelograms and in one it extended below the irradiated part of the spinal cord. Demyelination of the dorsal white columns of the spinal cord unaccompanied by vascular abnormality was seen below the irradiated part of the cord. It is suggested that radiation damages the endothelial cell barrier of capillaries and arterioles after a latent interval. Proteinous oedema fluid spreads through the white matter from the capillaries and also into the arteriolar walls narrowing these vessels enough to cause local ischaemia and infarction. It is further suggested that apart from ischaemia and infarction myelin is also damaged by poor nutrition associated with oedema fluid, and that radiation damage to oligodendroglial cells is not the cause of this additional demyelination in patients with radiation myelopathy.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
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