Early Postoperative Imaging Research Articles

Intrinsic tumors of the insula: a prospective surgical study of 30 patients.

Intrinsic insular tumors are frequently excluded from surgical treatment. The authors propose a more extensive approach to these lesions based on the results of this prospective series. From September 1993 to January 1995, 30 patients (18 males and 12 females; mean age 42 years) harboring benign (15 patients) or malignant (15 patients) tumors involving the insula underwent surgical treatment. The dominant and nondominant hemispheres were both affected in 15 cases. Two groups were defined on the basis of preoperative magnetic resonance (MR) imaging: 14 lesions were restricted to the insula and the corresponding opercula; the other 16 lesions also involved other mesocortical and/or allocortical areas. Most patients displayed only mild preoperative symptoms. The median score according to the Karnofsky performance scale was 90. Microsurgical removal was achieved via a transsylvian approach in nine cases and via a frontal and/or temporal approach in 21 cases. According to early postoperative MR imaging, complete tumor removal (100%) was seen in five patients, nearly complete (> 80%) in 21, and incomplete resection (50%-80%) in four patients. There was no operative mortality; 19 patients (63%) experienced immediate postoperative morbidity, including reduced performance. After a mean follow-up review of 8.5 months two of 21 patients suffered permanent deficits, accounting for an overall operative morbidity of 10%. At the mean time of review, three patients with Grade IV tumors had died of tumor recurrence. The authors conclude that low-grade intrinsic insular tumors, as well as Grade III tumors, can be removed with favorable results in the majority of patients. Surgery to excise glioblastomas should only be considered for patients with good preoperative performance and young age.

Surgery, Radiation, and Combination Therapy in the Treatment of Childhood Craniopharyngioma – A 20-Year Experience

The records of 61 children treated for primary craniopharyngioma at the Children's Hospital in Boston and The Joint Center for Radiation Therapy from 1970 to 1990 were reviewed to determine if any information could be obtained regarding the efficacy of surgery versus radiotherapy or a combination of these modalities for this tumor. A select group of 9 children treated without biopsy by radiation therapy alone were all alive without disease progression at follow-up. Although 9 of the 15 children who underwent surgery alone had tumor recurrence, 7 of the 37 children treated with radiotherapy following surgery have also recurred. Treatment morbidity occurred in all groups, but the 10-year actuarial survival for all patients was 91%. Early postoperative imaging and pre- and posttreatment endocrine and neuropsychologic evaluations need to be carried out in all prospective studies of the treatment of craniopharyngioma in children.

Sternocostoclavicular hyperostosis: its progression and radiological features. A study of 12 cases.

Twelve cases of sternocostoclavicular hyperostosis were followed up over four to 16 years. The patients underwent repeated radiological examinations of the sternocostoclavicular joints and the sternum, and the extrasternal osseous manifestations of the disease were studied to show changes in the radiological features during long term follow up. Five of 12 (41%) patients had extrasternal manifestations. With the exception of one patient extrasternal manifestations were first detected by scintigraphs because they were asymptomatic. With respect to the sternal manifestations the initial radiological diagnosis was made during an acute phase while painful swelling over the sternum and decreased mobility of the shoulders occurred. The radiological examinations showed the signs of a proliferative destructive arthritis in most patients. In contrast with the frequent occurrences of clinical symptoms, the radiological signs of progression take several years to become detectable. There are no specific bacteriological, serological or histological findings. Usually a permanent increase in the erythrocyte sedimentation rates is found. Sternocostoclavicular hyperostosis is a slowly progressing disease, characterised by a chronic aseptic destructive sternoclavicular arthritis with a reactive low turnover sclerosis that begins in a similar way to an enthesopathy and ends after several decades with total ankylosis. The radiological identification of retrosternal proliferation of soft tissue by computed tomography was found to be a valuable criterion for the differential diagnosis from other benign hyperostotic processes of the sternoclavicular region.

Computerized tomography and magnetic resonance imaging following cranial base surgery

The computed tomography scans and magnetic resonance imaging films of 57 patients who underwent anterior or anterolateral cranial base surgery from January 1987 to August 1989 were retrospectively reviewed to ascertain the significance of early and late postoperative intracranial imaging changes. Extra-axial changes (air, blood, cerebrospinal fluid collection) were found in 96% of patients; axial changes (brain edema, contusion) were seen in 30% of patients in the first postoperative period (72 hours). Subsequently, extra-axial changes began to resolve but axial changes became more prevalent. After 6 months, only axial changes persisted (encephalomalacia). It was encouraging to find a low correlation of imaging abnormalities with clinically significant findings.

Comparative roles of intraoperative epicardial and early postoperative transthoracic echocardiography in the assessment of surgical repair of congenital heart defects

In 94 consecutive patients undergoing surgical repair of congenital heart defects the results of intraoperative (after cardiopulmonary bypass) epicardial two-dimensional and Doppler color flow imaging were compared with those of sequential transthoracic echocardiography performed within 24 h of surgery and again before hospital discharge to define the precise role of intraoperative imaging. In 6 of 7 patients with a residual defect requiring immediate surgical revision, intraoperative imaging correctly identified the defect; spectral Doppler imaging underestimated or did not identify a residual outflow tract gradient in 17 patients. Left atrioventricular (AV) valve regurgitation after repair of complete AV septal defect was underestimated in three patients. Although intraoperative documentation of good ventricular function was usually associated with a good outcome, in three patients poor systemic ventricular function after cardiopulmonary bypass was not associated with early mortality. A minor degree of shunting around the patch was a common finding on epicardial and early postoperative imaging and persisted at the time of hospital discharge in 17 of 46 patients who had undergone patch closure of a ventricular septal defect as part of the surgical procedure. Additional trabecular septal defects were missed on color flow imaging after cardiopulmonary bypass in three patients, one of whom required subsequent reoperation. Although intraoperative two-dimensional and color flow imaging permitted the recognition of the majority of residual defects requiring immediate revision, residual outflow obstruction or AV valve regurgitation was usually underestimated.

Degree of reversibility of left ventricular systolic dysfunction after aortic valve replacement for isolated aortic valve stenosis

To determine whether a low preoperative left ventricular (LV) ejection fraction (EF) returns to normal late after aortic valve replacement for aortic stenosis, 42 patients with critical aortic stenosis (valve area 0.7 cm 2 or less), LV systolic dysfunction (EF 0.45 or less), angiographically normal coronary arteries, and no other significant valvular disease were studied at 10 to 84 months (mean 41 ± 21) postoperatively. All patients survived aortic valve replacement and were discharged clinically improved. There were 4 late deaths; these patients were older (79 ± 6 vs 64 ± 13 years, p = 0.007) and had lower preoperative mean valve gradients (51 ± 6 vs 68 ± 23 mm Hg, p = 0.003) than late survivors. Of 23 survivors who returned for follow-up radionuclide angiography and Doppler echocardiography, 21 were asymptomatic. EF returned to normal (0.50 or more) in 14 patients (group 1) and remained low in 9 patients (group 2). Doppler peak prosthetic valve gradient was 24 ± 8 mm Hg in group 1 and 25 ± 10 mm Hg in group 2 (difference not significant). Six of the 9 patients in group 2 underwent early postoperative radionuclide imaging, and LVEF was normal in 4 (0.65 ± 0.14 early vs 0.41 ± 0.06 late, p = 0.02). Of 77 preoperative and intraoperative variables analyzed, only paroxysmal nocturnal dyspnea (0 of 14 vs 4 to 9, p = 0.01) distinguished group 1 from group 2. Thus, LVEF does not always normalize after aortic valve replacement for AS, implying impaired myocardial contractility. In a subset of patients with low late postoperative LVEF, early postoperative LVEF was normal. Late mortality occurs in older patients with lower valve gradients, but overall clinical results are excellent and independent of postoperative EF.

Primary pulmonary cavitating carcinomas.

<h3>BACKGROUND AND PURPOSE:</h3> MR imaging findings of aneurysm enlargement, aneurysm wall enhancement, perianeurysmal edema, and embolic phenomena following deployment of flow-diverting stents may be relevant to those patients who subsequently experience procedure-related intracranial hemorrhage. We sought to document the routine early postoperative MR imaging findings following flow-diverting stent insertion. <h3>MATERIALS AND METHODS:</h3> Patients requiring flow-diverting stent placement for treatment or retreatment of cerebral aneurysms were prospectively included in the study during a 26-month period. Early postprocedural MR imaging studies were obtained and compared with preoperative imaging. Patient clinical outcome data were also collected. <h3>RESULTS:</h3> There were 34 stent-placement procedures during the study period. Aneurysm mural enhancement and mild new perianeurysmal edema were present in 50% and 14%, respectively. Any DWI lesion was present in 57% of cases. New or possibly new foci of susceptibility effect were found ipsilateral to the stent and not associated with diffusion restriction in 66% of cases. There were 2 cases (6%) of parenchymal hemorrhage and 2 major clinical complications (6%) causing permanent morbidity. <h3>CONCLUSIONS:</h3> Asymptomatic aneurysm mural enhancement is frequently seen following flow-diverting stent placement and should not necessarily be interpreted as a sign of impending aneurysm rupture. This finding often persists despite complete aneurysm occlusion. New small brain parenchymal susceptibility foci following stent placement have not previously been reported, to our knowledge, but were common in our series.