Regional cerebral and cerebellar blood flow were studied with Tc-99m HMPAO SPECT in a 74-year-old man with Weber's syndrome and a 67-year-old man with Claude-Nothnagel's syndrome. Significant cerebellar hypoperfusion was shown on the side contralateral to the mesencephalic cerebral infarct. The cerebellar hy-poactivity is caused by the interruption of the corticopontocerebellar pathways by the mesencephalic paramedian infarct associated with Weber's syndrome. In Claude's syndrome, the interruption of the dentatorubrothalamic pathways by the mesencephalic intermediolateral infarct explains the crossed cerebellar hypoperfusion. These findings confirm that mesencephalic infarcts can also be associated with crossed cerebellar diaschisis.

Indium-111 pentetreotide scintigraphy was performed in two patients for the localization of recurrent medullary thyroid carcinoma treated by surgery and external radiotherapy 1 and 10 years earlier. A marked uptake of the radiopharmaceutical was demonstrated in the lung areas that had been irradiated. These cases strongly suggest that this uptake is related to pulmonary fibrosis, a well-known complication of radiotherapy, even long after the irradiation. Therefore, attention must be paid to the avoidance of false-positive interpretation of somatostatin receptor scintigraphy in patients previously treated by radiotherapy.

BACKGROUND AND PURPOSE:Cerebral infarction and prolonged regional hypoperfusion have been described in patients with transient ischemic attacks (TIAs). The aim of this study was to compare the sensitivity of single-photon emission CT (SPECT) with that of brain CT and to evaluate the clinical significance of differentiation of TIA patients with or without focal hypoperfusion. METHODS:From a hospital-based population, we studied the SPECT and CT findings in 76 consecutive patients, without a stroke history, who presented with TIA in the carotid artery territory. The recorded variables were the time of SPECT, imaging (<36 or > or = 36 hours), clinical presentation, history of previous TIA(s), duration of the presenting attack (<2 or > or = 2 hours), vascular risk factors, and etiology. We used both visual and semiquantitative analyses for the SPECT evaluation. Acetazolamide challenge was not performed. RESULTS:The overall SPECT sensitivity was 36% (27/76). When brain CT and SPECT were performed in the same patients, the SPECT sensitivity was significantly higher than that of CT (19/59 [32%] versus 8/59 [14%]; P=.007). The SPECT sensitivity was not dependent on the time of investigation, duration of attacks, history of TIA(s), or the clinical presentation. The vascular risk and etiologic factors were not significantly different between the patients with or without prolonged focal hypoperfusion. Logistic regression did not identify any variable to discriminate the two groups. CONCLUSIONS:Despite its better sensitivity compared with CT, SPECT performed without the acetazolamide test provides no additional clinically useful information on the vascular risk factors and etiology in TIA patients.

Ischemia in the carotid artery territory due to atherosclerotic stenosis of the innominate artery is rare. We report a case in which transcranial Doppler ultrasonography (TCD) and SPECT with acetazolamide challenge proved the hemodynamic mechanism. The patient presented with three hypotensive TIAs in the right middle cerebral artery territory. Angiography showed a tight innominate artery stenosis and subclavian steal but no coexistent carotid or vertebrobasilar lesion. SPECT showed disturbed regional blood flow in the middle cerebral artery territory along with an exhausted perfusion reserve capacity. After angioplasty, flow velocities were normal and the perfusion reserve was restored. SPECT should be used to select patients at risk susceptible to benefit from angioplasty.

The sensitivity of single‐photon emission computed tomography (SPECT) in evaluating posterior mculation infarcts compared with that of computed tomography (CT) or magnetic resonance imaging (MRI) remains unknown. In a hospital‐based population, the authors studied SPECT, CT, and MRI in 35 consecutive patients presentmg with acute infarction clinically localized in the thalamus (7), posterior cerebral artery (PCA) territory (15), bramtem (19), and cerebellum (3) Multiple infarcts were noted m 8 patients. Overall, the SPECT sensitivity was lower than that of MRI (21% vs 93%, p ~ 0 004) and CT (42% vs 65%, p = 0 046) The SPECT and CT sensitivities were not Significantly different (67% vs 73%) for PCA Infarcts. Performed within 24 hours, SPECT showed a relevant hypoperfusion in all PCA mfarcts. For brainstem infarcts, CT (33%, p = 0 074) and MRI (91 %, p = 0.004) were more sensitive than SPECT, which showed no hemispheric hypoperfusion. The sensitivity of the three imaging techniques was 100% for large cerebellar infarcts. For the small group of thalamic infarcts, the SPECT, CT, and MRI sensitivities were 14, 71, and 100%, respectively. Thus, SPECT compared to CT and MRI is not helpful in the subacute phase to localize PCA and cerebellar infarcts and is of limited value for thalamic infarcts. In the first hours, the absence of cerebral hypoperfusion in brainstem mfarcts may help to differentiate them from hemispheric infarcts usually associated with profound hypoperfusion.

To address the issue of whether single-photon emission computed tomography (SPECT) may add useful topographic information to neurologic examination in clinical practice, we compared technetium-99m hexamethyl propyleneamine oxime (HMPAO) SPECT and brain CT in 100 consecutive stroke patients involving the following clinical vascular territories: cortical middle cerebral artery (CMCA), 52; deep, 39; anterior cerebral artery (ACA), 3; posterior cerebral artery (PCA), 7. SPECT and CT sensitivity were calculated as the percentage of patients with respectively focal hypoperfusion or hypodensity related to the index event. The overall sensitivity of SPECT was not significantly different from CT (69 vs. 73%). The sensitivity of SPECT was not significantly dependent on the time of investigation (72% within 24 h, 50% on day 2, and 71 % after day 3). Compared with CT, the sensitivity of SPECT was statistically significantly higher in CMCA infarcts (89 vs. 71%; p = 0.027) and lower in deep infarcts (40 vs. 69%; p = 0.024). The degree of hypoperfusion was significantly higher in cortical lesions than in deep lesions (27 vs. 9%; p < 0.001). Crossed cerebellar diaschisis seemed less frequent in patients with clinical lesion in the ACA and PCA territory (respectively 30 and 40%) and was not significantly different when the ischemic lesion involved the CMCA (56%) or deep territories (50%). No significant difference was found when SPECT took place within or after 48 h. Thus, the selective SPECT sensitivity according to the site of lesion and the degree of hypoperfusion may help to determine stroke subtypes in the acute phase. In contrast, in the subacute phase, SPECT is as sensitive as CT in mapping the ischemic lesion and should not be recommended for this purpose.

We analysed retrospectively the results obtained during 3 years in the treatment of thyrotoxicosis with 131-iodine. A group of 32 patients, including 21 Graves' diseases, 10 multinodular toxic goitres and 1 toxic adenoma has been collected. The therapeutic efficacy of one dose of radioiodine, assessed after 6 months was 100% in toxic multinodular goitres and 57% in Graves' diseases. No acute complications were observed. The best radiosensitivity of toxic multinodular goitres compared with diffuse goitres is probably due to the mechanisms themselves of thyrotoxicosis in these diseases. Results also suggest that multinodular toxic goitres in our country should be systematically treated with antithyroid drugs before radioiodine. In Graves' disease, no predictive factor of the early response to therapy could be definitely evidenced. Finally, clinicians should be aware of the advantages of such a treatment of thyrotoxicosis which is not very aggressive and at least definitive.

This study reports on the proximal femur mineral content in 36 Type 1 and 60 Type 2 diabetic patients. Bone mass measurements were performed in the neck, Ward's triangle and in the trochanteric area of the femur, using dual-photon absorptiometry with 153Gd. Bone mineral density (BMD) was significantly decreased in Type 1 diabetic men and women as well in Type 2 men, when compared with a non diabetic matched population. In Type 1 men, neck and Ward's triangle densities were reduced from 0.94 +/- 0.05 to 0.86 +/- 0.11 (p = 0.007) and from 0.87 +/- 0.10 to 0.74 +/- 0.14 g.cm-2 (p = 0.011), respectively. In Type 1 women, BMD was reduced from 0.97 +/- 0.10 to 0.90 +/- 0.10 g.cm-2 (p = 0.023) in the femoral neck. In Type 2 men, BMD in Ward's triangle was also significantly lower than in controls: 0.69 +/- 0.14 vs 0.76 +/- 0.19 g.cm-2, respectively (p = 0.001). In contrast, no bone loss was observed in a group of Type 2 overweight diabetic women. No statistical correlation was observed between bone loss and age, duration of diabetes, body mass index, C-peptide levels, daily insulin doses, HbA1 and the presence of diabetic complications. In conclusion, long-standing Type 1 diabetic men and women and Type 2 diabetic men have a decrease in the proximal femur bone mass. Type 2 diabetic women appear to be protected from diabetic osteopenia.

Five right-handed patients with pure transient global amnesia were evaluated with technetium-99m hexamethylpropyleneamine oxime single photon emission computed tomography after the amnesic attack. Independent of the interval between the procedure and the amnesic episode, single photon emission computed tomography demonstrated a decreased cerebral blood flow in the left temporal lobe in one patient and in the left parietotemporal region in three patients, with a more marked reduction in the temporal lobe. The remaining three patients were normal. A control single photon emission computed tomographic study was carried out in one patient 3 months after the amnesic attack and showed a left-sided persistent temporal hypoperfusion. These findings suggest that in some patients, transient global amnesia can be due to a vascular mechanism requiring strong investigations for vascular risk factors and appropriate treatment. During a follow-up period of 12 to 32 months, none of the patients with regional hypoperfusion suffered cerebrovascular events, suggesting that single photon emission computed tomography has no predictive value for further stroke.

To the Editor. —In a Special Communication of September 5 about silent myocardial ischemia, Barsky et al1emphasize the importance of the person in the so-called silent ischemia syndrome. They summarize interesting previous findings about symptom perception, appraisal, and reporting that can be taken into account to explain the absence of anginal symptoms in these patients. However, they state that "a link between denial and silent ischemia is yet to be established." Actually, it has been. We published empirical evidence supporting the hypothesis of such an "undercomplaining behaviour pattern" in silent myocardial ischemia.2Our answer to the question "What is actually silent in asymptomatic coronary artery disease, the patient himself or the ischemia?" was that patients with silent myocardial ischemia deny not only pain but also sickness, illness seriousness, and even the presence of a cardiac disease. Confirmatory data were published in a second study,3which

This study was designed to compare the positive inotropic properties of enoximone, a cardiac phosphodiesterase III inhibitor, with those of dobutamine in a population of moderate to severe congestive heart failure patients. The end-systolic pressure-volume relationship method was used. In addition, the haemodynamic effects of both drugs were compared. In seven of the 11 patients studied, enoximone induced a significant shift upwards and to the left of the end-ejection pressure/end-systolic volume (EEP/ESV) relation, giving evidence of a true positive inotropic effect. In the remaining patients, improvement in cardiac pump function was observed together with a shift of the EEP/ESV relation along the line of iso-inotropism and appeared to be the result of the vasodilatory effect of the drug alone. Data from nine patients were available for comparison with dobutamine which induced a shift upward and to the left of the EEP/ESV relation in seven patients. At the therapeutic doses chosen, the difference between the inotropic effects of the two drugs was not significant (P = 0.07). Of the three patients available for comparison who did not manifest inotropic response with enoximone, two were also dobutamine 'non-responders': they differed from the 'responder' patients in two respects: they had undergone surgery for correction of valvular disease and had significantly higher pulmonary artery pressures. The haemodynamic measurements confirmed the vasodilatory properties of enoximone; in particular, the fall in ventricular filling pressures was much greater with enoximone than with dobutamine.(ABSTRACT TRUNCATED AT 250 WORDS)

The internal mammary artery is considered the best available conduit for coronary artery bypass grafting. The high long-term patency rate of mammary artery grafts as opposed to saphenous vein grafts seems to result from favorable biologic properties that could protect this vessel against atherosclerosis. Recent studies have emphasized the role of endothelium in triggering or modulating mechanisms controlling the growth, metabolism and contractile status of smooth muscle cells. Endothelial cells produce several vasoconstrictor agents such as thromboxane and endothelin and vasodilators among which prostacyclin and endothelium-derived relaxing factor or nitric oxide. In addition to their effects on vasomotor tone, these agents influence platelet adhesion and aggregation that may be implicated in atherogenesis. Differences exist among different vessels in the amount of nitric oxide released in basal conditions, in the agents stimulating its production and in the sensitivity of vascular smooth muscle to that factor [1–4]. Similarly, various areas of the vascular system are different in their ability to produce prostacyclin [5].

The diagnostic value of exercise electrocardiography and thallium myocardial scintigraphy for the detection of restenosis was assessed in 111 patients undergoing control angiography 6 months after successful coronary angioplasty. All patients were free of symptoms at the time of the study. A diameter reduction of 70% or more at the site of angioplasty was considered restenosis. The sensitivity of exercise electrocardiography is low (64%). Exercise ECG and scintigraphy are highly specific (respectively 90% and 93%). The predictive value of a positive ECG or thallium scintigraphy is poor (respectively 53% and 63%). The value of a negative scintigraphic result is slightly better than the predictive value of a negative ECG (98% vs 95%; NS). A negative exercise scintigraphy almost excludes severe restenosis. These non-invasive tests seem suitable for the detection of asymptomatic restenosis.

Journal Article Psychological determinants of silent myocardial ischaemia Get access P. Janne, P. Janne 1Department of Psychosomatic MedicineUniversity of Louvain, Cliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar C. Reynaert, C. Reynaert 1Department of Psychosomatic MedicineUniversity of Louvain, Cliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar L. Cassiers, L. Cassiers 1Department of Psychosomatic MedicineUniversity of Louvain, Cliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar W. Huber, W. Huber 1Department of Psychosomatic MedicineUniversity of Louvain, Cliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar P. De Coster, P. De Coster 2Division of Cardiology, University of LouvainCliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar B. Marchandise, B. Marchandise 2Division of Cardiology, University of LouvainCliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar R. Kremer R. Kremer 2Division of Cardiology, University of LouvainCliniques de Mont-Godinne, B5180 Yvoir, Belgium Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, Volume 8, Issue suppl_G, October 1987, Pages 125–129, https://doi.org/10.1093/eurheartj/8.suppl_G.125 Published: 01 October 1987

A nongeometric radionuclide technique with correction for attenuation was used for the determination of cardiac output and stroke volume during exercise in nine normal subjects and in ten hypertensive patients. Simultaneous reference stroke volume (range 48-159 ml) and cardiac output (range 3.6-23.8 l/min) measurements were obtained by the Fick method. Data were collected at rest and during 60 degrees upright exercise, at two or three levels of increasing severity. Three statistical measurements were used for the comparison of both methods: correlation, precision, and accuracy. Radionuclide and Fick cardiac output measurements (n = 67, rest and exercise data) correlated well (r = 0.90). For stroke volume, the correlation was less (r = 0.64); however, the precision or random variability of both methods was similar for stroke volume (radionuclide: 8 ml or 9%; Fick: 16 ml or 16%). The accuracy or systematic error was defined as the mean difference between radionuclide and Fick measurements. The radionuclide method underestimated the Fick measurements. The systematic error was 18 +/- 18 ml for stroke volume and 2.4 +/- 2.4 l/m for cardiac output. A similar comparison of both methods was made on the absolute changes of stroke volume (r = 0.61; range -19 + 70 ml) and cardiac output (r = 0.82; range +1.6 + 16.4 l/m) between rest and exercise. The precision of the two methods was similar; the systematic error was 1.9 +/- 2.2 l/m for cardiac output and 6 +/- 17 ml for stroke volume. Thus, in these two groups of patients, although radionuclide and Fick cardiac output measurements at rest and during exercise correlated well, the radionuclide values were systematically and significantly lower.