Background: Borrelia infections, especially chronic neuroborreliosis ( NB), may cause considerable diagnostic problems. This diagnosis is based on symptoms and findings in the cerebrospinal fluid but is not always conclusive. Purpose: To evaluate brain magnetic resonance imaging ( MRI) in chronic NB, to compare the findings with healthy controls, and to correlate MRI findings with disease duration. Material and Methods: Sixteen well- characterized patients with chronic NB and 16 matched controls were examined in a 1.5T scanner with a standard head coil. T1- ( with and without gadolinium), T2-, and diffusion- weighted imaging plus fluid- attenuated inversion recovery ( FLAIR) imaging were used. Results: White matter lesions and lesions in the basal ganglia were seen in 12 patients and 10 controls ( no significant difference). Subependymal lesions were detected in patients down to the age of 25 and in the controls down to the age of 43. The number of lesions was correlated to age both in patients ( rho=0.83, P < 0.01) and in controls ( rho=0.61, P < 0.05), but not to the duration of disease. Most lesions were detected with FLAIR, but many also with T2- weighted imaging. Conclusion: A number of MRI findings were detected in patients with chronic NB, although the findings were unspecific when compared with matched controls and did not correlate with disease duration. However, subependymal lesions may constitute a potential finding in chronic NB.

Background: Rectal administration of enemas, foams and suppositories is the most efficient way to deliver locally acting drugs to the distal colon. Ropivacaine, a long-acting local anaesthetic, was chosen as a candidate for a new rectal treatment of ulcerative colitis. Aim: To determine the colonic spread of a rectal ropivacaine formulation. Methods: In this randomized, incomplete cross-over study, 12 male volunteers were given 200 mg ropivacaine HCl rectally in 20, 40, 60 and 80 mL hydroxypropyl methylcellulose gel. The viscosity of the gel was 1.1 Pa s. The spread of the radiolabelled ( 99mTc-labelled diethylenetriaminepenta-acetic acid) formulations was assessed by gamma-scintigraphy. Plasma was collected and analysed for ropivacaine base. Results: The retrograde spread was limited to the descending colon and the difference between the studied volumes was not statistically significant. Only the 80-mL volume tended to have a larger distribution, although the 20-mL volume showed the same maximal distribution in two subjects. No distinct relationship between volume, retrograde colonic spread and plasma concentrations could be found. Ropivacaine was well tolerated. Conclusions: Rectal ropivacaine gel in all volumes between 20 and 80 mL can spread up to the descending colon. There was no relationship between either retrograde colonic spread or the administered volume and the ropivacaine plasma concentrations.

BACKGROUND: The use of iodinated contrast medium can result in nephropathy. Whether iso-osmolar contrast medium is less nephrotoxic than low-osmolar contrast medium in high-risk patients is uncertain. METHODS: We conducted a randomized, double-blind, prospective, multicenter study comparing the nephrotoxic effects of an iso-osmolar, dimeric, nonionic contrast medium, iodixanol, with those of a low-osmolar, nonionic, monomeric contrast medium, iohexol. The study involved 129 patients with diabetes with serum creatinine concentrations of 1.5 to 3.5 mg per deciliter who underwent coronary or aortofemoral angiography. The primary end point was the peak increase from base line in the creatinine concentration during the three days after angiography. Other end points were an increase in the creatinine concentration of 0.5 mg per deciliter or more, an increase of 1.0 mg per deciliter or more, and a change in the creatinine concentration from day 0 to day 7. RESULTS: The creatinine concentration increased significantly less in patients who received iodixanol. From day 0 to day 3, the mean peak increase in creatinine was 0.13 mg per deciliter in the iodixanol group and 0.55 mg per deciliter in the iohexol group (P=0.001, the increase with iodixanol minus the increase with iohexol, -0.42 mg per deciliter [95 percent confidence interval, -0.73 to -0.22]). Two of the 64 patients in the iodixanol group (3 percent) had an increase in the creatinine concentration of 0.5 mg per deciliter or more, as compared with 17 of the 65 patients in the iohexol group (26 percent) (P=0.002, odds ratio for such an increase in the iodixanol group, 0.09 [95 percent confidence interval, 0.02 to 0.41]). No patient receiving iodixanol had an increase of 1.0 mg per deciliter or more, but 10 patients in the iohexol group (15 percent) did. The mean change in the creatinine concentration from day 0 to day 7 was 0.07 mg per deciliter in the iodixanol group and 0.24 mg per deciliter in the iohexol group (P=0.003, value in the iodixanol group minus the value in the iohexol group, -0.17 mg per deciliter [95 percent confidence interval, -0.34 to -0.07]). CONCLUSIONS: Nephropathy induced by contrast medium may be less likely to develop in high-risk patients when iodixanol is used rather than a low-osmolar, nonionic contrast medium.

Objective. Platelet inhibition during percutaneous coronary intervention (PCI) generally reduces adverse cardiac events. There are very few data on the combination of aspirin and the platelet adenosine diphosphate-receptor inhibitor clopidogrel given before the intervention. Design. In a non-randomized comparison, a total of 706 consecutive patients received clopidogrel 375 mg in addition to aspirin on the day before PCI. The control group consisted of 724 consecutive PCI patients receiving only aspirin pre-treatment. Results. The two groups were well balanced regarding baseline characteristics. Pre-treatment with clopidogrel reduced the in-hospital composite of death, myocardial infarction or urgent revascularization by 41% compared to the control (8.2% versus 4.8%, respectively, p = 0.010). This was due to a decreased incidence of myocardial infarction (7.2% versus 4.4%, p = 0.024) and percutaneous reintervention (1.2% versus 0.3%, p = 0.039). There was no difference in femoral complications between the groups. For every patient in the clopidogrel group, there was a cost reduction of SEK 447 ($40 United States currency). Conclusion. Clopidogrel treatment in addition to aspirin before PCI was associated with a reduction of inhospital adverse cardiac events. It was also safe and cost-saving.

Att utvärdera det vetenskapliga underlaget för olika åtgärder mot fetma hos vuxna och barn. Underlaget för såväl förebyggande åtgärder som olika behandlingsformer granskats. Bland behandlingsmetoderna ingår kost/diet, motion, beteendeterapi, läkemedel, alternativmedicinska och kirurgiska metoder.

In X-ray diagnostics, radiation that is partly transmitted through and partly absorbed in the irradiated object is utilised. An X-ray image shows the variations in transmission caused by structures in the object of varying thickness, density or atomic composition.

After an introductory description of the nature of X-rays, the most important processes in the X-ray source, the object (patient) and radiation detector for the generation of an X-ray image will be described.

We aimed to quantify the benefits of detecting ductal carcinoma in situ (DCIS) and of downwards stage-shifting within invasive tumours in mammographic screening. Using data from the Swedish Two-County Trial of breast cancer screening, we examined the 20-year death rates from invasive tumours of stage II or worse, invasive tumours of stage I and DCIS. We then used these rates and their respective incidences in invited (active study population, ASP) and control (passive study population, PSP) arms of the trial, to estimate the numbers of deaths avoided by downward stage-shifting the larger stage II or worse tumours to stage I and the stage I cancers to DCIS. We also studied the association between the mortality reduction achieved and the proportion of DCIS cases detected in the randomised trials of breast cancer screening. In the Swedish Two County Trial, 141 breast cancer deaths were avoided in the ASP compared with the PSP at approximately 20 years of follow-up. Of these, 65% (91/141) were avoided as a result of stage-shifting from invasive stage II or worse to invasive stage I, and 5% (7/141) as a result of stage-shifting from invasive stage I to DCIS. If we assumed that 10% of stage II or worse tumours avoided were shifted not to stage I, but to DCIS, the estimated number of deaths prevented by shifting from invasive disease to in situ was 17, which is 12% of all deaths prevented. When the results of all the randomised trials of breast cancer screening were reviewed, there was no clear association between the percentage of DCIS cases diagnosed and the observed mortality reduction. We conclude that compared with downward stage-shifting of invasive tumours, detection of DCIS plays a small part in saving lives from breast cancer. Treatment decisions in DCIS, as in invasive carcinoma, should take full account of histopathological, clinical and radiological attributes of the tumour. ⌐ 2003 Elsevier Ltd. All rights reserved.

The several successful solutions to the problem of image reconstruction from projections have caused a rapid growth of a number of new techniques for the reconstruction of distributions and images in several scientific fields. The importance of these techniques, especially in medicine, can hardly be overestimated.

In a new algorithm for image reconstruction from projections [l, 2], a special form of the projection data is employed providing some certain advantages. This new form or map of the projection data are called linograms.

This is intended as an overview of linograms and the algorithm based on them. Thorough discussions of conventional techniques are to be found in [3, 4 and 5]. In conventional techniques for image reconstruction, a two dimensional distribution of some property is reconstructed. The property might be the x-ray attenuation in a cross-section of the body, the distribution of a radioactive substance or something else. The distribution is not directly accessible but it is possible to measure line integrals (rays) through i t. The problem now is to reconstruct the distribution (the image) from i ts line integrals (its projections).

Let the property we are interested in be described by the function f(x, y). projection data are estimates of line integrals of f of known location. Incon~entional techniques each line is specified by two parameters s and e, where s is the (signed) distance from the origin and e its angle with the y-axis.

A fast and simple method for three-dimensional shape description is described. The method views a 3D object as a radial distance function on the unit sphere, and thus reduces the dimensionality of the description problem by one. The radial distance function is approximated by Fourier methods in the basis of the spherical harmonic polynomials. The necessary integration is carried out on the object boundary, rather than on the unit sphere. Consequently, there is no need of a parameterisation of the object surface. The description makes it possible to compare shapes in a computationally very simple way. Solutions on how to cope with translated and rotated objects are discussed. The method is developed for star-shaped objects, but is stable even if the input image is non-star-shaped. The method is tested in a data set from magnetic resonance imaging (MRI) of the brain. Potential medical applications are discussed. ⌐ 2002 Elsevier Science Ireland Ltd. All rights reserved.

OBJECTIVE : This study describes the production, under strictly standardized and controlled conditions, of radiofrequency lesions with identical neurogenerator settings: in vitro in two different albumin solutions (nongelatinous and gelatinous) and in vivo in the thalamus of the pig.

METHODS : The radiofrequency lesions were investigated in vitro by the use of a specially designed video system and in vivo by magnetic resonance imaging. Moreover, the size of the in vivo lesions was estimated with the use of histological sectioning. The statistical analysis included the calculation of a correlation coefficient for the length, width, and volume for each lesion estimation.

RESULTS : A high correlation (R = 0.96, P < 0.005; n = 14) was found between clot sizes in the two albumin solutions. Albumin clots generated in gelatinous albumin showed systematically larger volumes. In the pig, two concentric zones were seen in all magnetic resonance images and all histological preparations. The width correlation of the completely coagulated brain tissue (inner zones) was R = 0.94, P < 0.005, and n = 7. The corresponding correlation between magnetic resonance images and gelatinous albumin was R = 0.93, P < 0.005, and n = 7. As a rule, the in vitro clots were smaller than the outer zone but larger than the inner zone of the magnetic resonance imaging-recorded lesions for all of the electrode and temperature combinations tested. In vivo lesions generated with the same electrode and parameter settings showed high reproducibility.

CONCLUSION : The value of presurgical electrode tests to validate the electrode function and lesion size in vitro has become evident in this study, which shows a high correlation between the in vitro albumin clots and the in vivo lesions observed on magnetic resonance images.

Purpose: To prospectively register fluoroscopic and cine times in a random fashion, and to measure patient radiation exposure from routine coronary angiography and coronary balloon angioplasty. We also evaluated an optional dose reduction system used during interventions. Material and Methods: The incident radiation to the patient was measured as kerma area product (KAP) in Gycm2, obtained from an ionisation chamber mounted on the undercouch tube during 65 coronary angiography procedures and another 53 percutaneous transluminal coronary angioplasties (including 29 stent procedures), mostly directly following complete coronary angiography. Results and Conclusion: The values from coronary angiography were comparable to other reports with a mean fluoroscopic time of 4.4 min and a mean KAP value of 62.6 Gycm2. The corresponding figures from coronary balloon angioplasty without stenting were lower than otherwise reported, with 8.2 min and 47.9 Gycm2, respectively. The use of coronary stents did prolong the mean fluoroscopic time (10.5 min) but did not significantly enhance the patient mean radiation dose (51.4 Gycm2). The dose reduction technique resulted in a significant KAP value reduction of 57%. In conclusion, with regard to radiation exposure, coronary angiography and balloon angioplasty are considered safe procedures.

Radiation dose and image quality in diagnostic radiology. Optimization of the dose-image quality relationship with clinical experience from scoliosis radiography, coronary intervention and a flat-panel detector.

X-rays are known to cause malignancies, skin damage and other side effects and they are thus potentially dangerous. Therefore, it is essential and in fact mandatory to reduce the radiation dose in diagnostic radiology as far as possible. This is also known as the ALARA (As Low As Reasonably Achievable) principle. However, the dose is linked to image quality and the image quality may not be lowered so far that it jeopardizes the diagnostic outcome of a radiographic procedure. The process of reaching this balance between dose and image quality is called optimization. The aim of this thesis is to propose and evaluate methods for optimizing the radiation dose - image quality relationship in diagnostic radiography with a focus on clinical usefulness. The work was performed in three main parts.

Optimization of scoliosis radiography: In the first part, two recently developed methods for digital scoliosis radiography (digital exposure and pulsed fluoroscopy) were evaluated and compared to the standard screen-film method. Radiation dose was measured as Kerma area-product (KAP), Entrance surface dose (ESD) and effective dose; image quality was assessed with a contrastdetail phantom and through Visual grading analysis. Accuracy in angle measurements was also evaluated. The radiation dose for digital exposure was nearly twice as high as the screen-film method at a comparable image quality while the dose for pulsed fluoroscopy was very low but with a considerably lower image quality. The variability in angle measurements was sufficiently low for all methods. Then, the digital exposure protocol was optimized to a considerably lower dose with a slightly lower image quality compared to the baseline.

Flat-panel detector: In the second part, an amorphous-silicon direct digital flat-panel detector was evaluated using a contrast-detail phantom, measuring dose as entrance dose. The flat-panel detector yielded a superior image quality at a lower dose than both storage phosphor plates and screen-film. Equivalent image quality compared to storage phosphor plates was reached at about one third of the dose.

Optimization of percutaneous coronary intervention (PCI): In the third part, influence of various settings on radiation dose and image quality in coronary catheterisation and PCI was investigated. Based on these findings, the dose rate for fluoroscopy was reduced to one-third. The dose reduction was evaluated in a clinical series of 154 PCI procedures before and 138 after the optimization. Through this optimization, the total KAP was significantly reduced to two-thirds of the original value.

In summary, this thesis indicates the possibility of dose reduction in diagnostic radiology through optimization of the radiographic process.

BACKGROUND AND PURPOSE: Spectroscopic studies (¹H-MR spectroscopy) of normal-appearing white matter (NAWM) in patients with multiple sclerosis (MS) with MR imaging brain lesions have already been performed, but our intention was to investigate NAWM in MS patients who lack brain lesions to elucidate whether the same pathologic changes could be identified.

MATERIALS AND METHODS: We checked 350 medical files of patients with MS who are registered in our institution. Fourteen patients (11 women and 3 men; mean age, 48.6 years; handicap score, Expanded Disability Status Scale [EDSS] 2.9; range, 1–6.5) with clinically definite MS and a normal MR imaging of the brain were included. ¹H-MR spectroscopy was performed in 4 voxels (size approximately 17 × 17 × 17 mm³) using absolute quantification of metabolite concentrations. Fourteen healthy control subjects (11 women and 3 men; mean age, 43.3 years) were analyzed in the same way.

RESULTS: Significant differences in absolute metabolite concentrations were observed, with the patients with MS showing a lower total concentration of N-acetyl compounds (tNA), including N-acetylaspartate and N-acetyl aspartylglutamate (13.5 mmol/L versus 14.6 mmol/L; P = .002) compared with the healthy control subjects. Unexpectedly, patients with MS presented significantly lower choline-containing compounds (Cho) compared with healthy control subjects (2.2 mmol/L versus 2.4 mmol/L; P < .001). The EDSS showed a positive correlation to myo-inositol concentrations (0.14 mmol/L per EDSS; r² = 0.06) and a negative correlation to tNA concentrations (−0.41 mmol/L per EDSS; r² = 0.22).

CONCLUSION: The unexpected finding of lower Cho concentrations has not been reported previously. We suggest that patients with MS who lack lesions in the brain constitute a separate entity and may have increased protective or healing abilities.

Massive haemoptysis represents a major medical emergency that is associated with a high mortality. Here we present two cases of life-threatening haemoptysis, the first caused by rupture of an aortic aneurysm into the lung in a 37-yr-old woman with polyarteritis nodosa and the second caused by massive bleeding from an angiectatic vascular malformation in the right main bronchus in a 21-yr-old woman. Fibreoptic bronchoscopy played an essential role in the diagnostic process and management of the respiratory tract. Diagnosis in the first case was obtained by CT scan and the aneurysm was treated surgically. In the second case, bronchial arteriography contributed to both definitive diagnosis and treatment. Initial cardiorespiratory management, diagnostic procedures and definitive therapy are described and reviewed. Adequate early management of the cardiorespiratory system is essential to the outcome. Aggressive measures to elucidate the cause of haemoptysis and prompt therapy are warranted because of the high risk of recurrence.

Objective.  To investigate individual variations of platelet inhibition after clopidogrel-loading doses.

Setting.  Department of Cardiology, Linköping University Hospital, Linköping, Sweden.

Subjects.  Individuals with stable angina pectoris (n = 18) subject to percutaneous coronary interventions (PCI) and subsequent stenting were investigated.

Methods and experimental protocol.  A 300-mg clopidogrel loading dose was administrated immediately after stenting (day 1) followed by an additional 75 mg clopidogrel after 24 h (day 2). The ADP-evoked platelet fibrinogen binding was analysed to estimate platelet reactivity immediately before angiography and on day 2. A flow cytometry technique was used with two ADP solutions (final concentrations 0.6 and 1.7 μmol L⁻¹) employed as platelet activating agents. Soluble P-selectin was used as a marker of platelet activity.

Results.  When using 1.7 μmol L⁻¹ ADP to activate platelets four individuals had a strong inhibition (i.e. platelet reactivity <10% of the day 1-value day 2). In contrast, five patients demonstrated a weak inhibition (i.e. platelet reactivity >60% of the day 1-value day 2). Similar results were obtained when using 0.6 μmol L⁻¹ ADP as a platelet-activating agent. Clopidogrel, however, fails to suppress platelet activity as estimated from soluble P-selectin.

Conclusions.  Clopidogrel evoked platelet inhibition exhibits a considerable individual heterogeneity. Some individuals only had weak responses whereas others displayed strong platelet inhibition. The present flow cytometry technique appears suitable for identifying patients with abnormal reactions after clopidogrel exposure.

Partly based on magnetic resonance imaging studies, the "plumb-bob" approach for brachial plexus block was designed to minimize the risk of pneumothorax. Nevertheless, the risk of pneumothorax has remained a concern. We analyzed magnetic resonance images from 10 volunteers to determine whether the risk of pneumothorax was decreased with this method. The recommended initial needle direction is anteroposterior through the junction between the lateral-most part of the sternocleidomastoid muscle and the superior edge of the clavicle. If the initial placement is not successful, the brachial plexus may be sought in sectors 20░-30░ cephalad or caudad to the anteroposterior line in a sagittal plane through the insertion point. We found that the anteroposterior line reached the pleura in 6 of 10 volunteers without prior contact with the subclavian artery or the brachial plexus, but always with contact with the subclavian vein. To reach the middle of the brachial plexus, a mean cephalad redirection of the simulated needle by 21░ was required (range from 41░ cephalad to 15░ caudad in one case). We conclude that the risk of contacting the pleura and the subclavian vessels may be reduced by initially directing the needle 45░ cephalad instead of anteroposterior. If the brachial plexus is not contacted, the angle should be gradually reduced.

Background: There is an unsettled discussion about whether the distribution of local anesthetic is free or inhibited when performing brachial plexus blocks. This is the first study to use magnetic resonance imaging (MRI) to help answer this question. Methods: Thirteen patients received axillary block by a catheter-nerve stimulator technique. After locating the median nerve, a total dose of 50 ml local anesthetic was injected via the catheter in four divided doses of 1, 4, 15, and 30 ml. Results of sensory and motor testing were compared with the spread of local anesthetic as seen by MRI scans taken after each dose. The distribution of local anesthetic was described with reference to a 20-mm diameter circle around the artery. Results: Thirty minutes after the last dose, only two patients demonstrated analgesia or anesthesia in the areas of the radial, median, and ulnar nerve. At that time, eight of the patients had incomplete spread of local anesthetic around the artery, as seen by MRI. Their blocks were significantly poorer than those of the five patients with complete filling of the circle, although incomplete blocks were also present in the latter group. Conclusion: This study demonstrated that MRI is useful in examining local anesthetic distribution in axillary blocks because it can show the correlation between MRI distribution pattern and clinical effect. The cross-sectional spread of fluid around the brachial-axillary artery was often incomplete-inhibited, and the clinical effect often inadequate.

In the supraclavicular lateral paravascular approach for brachial plexus regional anesthesia by Moorthy et al. (Moorthy's block), the patient is supine with the ipsilateral shoulder displaced anteriorly 5-8 cm. The needle direction is precisely defined in the coronal plane (using a Doppler flowprobe) but not in the sagittal plane. We sought to determine whether the block could be simplified by keeping the shoulder in a neutral position, if the needle direction in the sagittal plane could be more precisely described, and if the risk of pneumothorax appeared acceptably small. These questions were studied by magnetic resonance imaging in 10 volunteers. Volume datasets of the periclavicular region allowed precise positioning of simulated needles. In all volunteers, Moorthy's block could be performed with the shoulder in a neutral position. The optimal needle trajectory passed 5 mm posterior to the clavicle and was 25░ posterior to the coronal plane, never approaching the pleura closer than 18 mm. We conclude that Moorthy's block can be performed with the shoulder in a neutral position, that more precise instructions for the needle direction can be given, and that the risk of pneumothorax seems minimal. This should be confirmed by a clinical study.

In patients with unilateral hearing loss and dizziness it is important to rule out a cerebellopontine angle process. This is often done by audiological and otoneurological investigations. However, in many cases we must rely on the imaging of the temporal bone and the cerebello-brainstem area. The paper has presented the three dimensional (3D) Fast Spin-Echo (FSE) T2 weighted, 0.7 mm thick MR images, which in addition to being quick, does not require the use of expensive contrast material. Between September 1996 and November 1997, 152 patients with unilateral hearing loss and/or balance disorders were investigated. In normal cases the 7th and 8th nerves could be followed accurately from the brainstem to the internal auditory meatus. The found tumors were hypointense compared to the cerebrospinal fluid and could be outlined with reasonable accuracy even without gadolinium contrast. The inner ear had high signal, like cerebrospinal fluid. The patency of the cochlea could be estimated accurately. Thus, 3D FSE T2 weighted images can reliably differentiate between patients with and without pathologies of the cerebellopontine angle. The use of gadolinium contrast could be avoided in most of the cases, but contrast is necessary for differential diagnostic purposes in patients with alterations in the cerebellopontine angle or in doubtful cases.

This thesis focus on the physiological information, on left ventricular (LV) motion in the long axis, evaluated in routine coronaty angiography sequences and based on previous knowledge from echocardiographic studies. As coronary angiography has become a very frequent examination, a method for assessment of LV function from routine coronary angiograms would probably have a significant impact on clinical work. Therefore, the motion of the left coronary artery is analysed in the studies described below.

In a pilot study of 84 patients, refetTed for coronaty and LV angiography, the systolic descent of the left coronary ostium (LCO) towards apex was measured. This simple manual measure from routine coronary angiograms showed a mean amplitude of 9.6 mm (range 3.0-15.0) and significant linear correlation to ejection fraction (EF) (r = 0.72, SEE = 10.1, p < 0.001).

In the second study, including 28 patients, coronary angiography and echoeardiography was used for measurement of circumflex artery motion (CAM) and mitral annulus motion (MAM) respectively. CAM amplitude tended to be higher than MAM in the higher range of amplitudes while the opposite was found in the lower range of amplitudes.

In a eehocardiographic study of another 26 patients; it was found in 13 patients with normal EF that the motion amplitude of a site epicardially at the most basal lateral patt of the LV wall was significantly (p < 0.001) higher than endoeardially, but in 13 patients with decreased EF (< 50%) there was no significant difference between the two sites. The motion amplitude epicardially corresponds to the motion amplitude of the circumflex artery.

In the 13 patients with normal EF the motion amplitude of the closed mitral valves was significantly lower than the motion amplitude epi- and endocardially during systole, with a rather conic shape of the atrioventricular plane (AVP) at the onset of systole. In end-systole the different parts of the left AVP, the epicardial part (circumflex artery), the endocardial part (mitral annulus) and the valves were almost on the same level.

In the third study, including 73 patients referred for coronary and LV angiography, the systolic descent of LCO and of the circumflex artery towards apex was measured manually. The mean motion amplitude of LCO (9.1 mm, range 1.7-19.7) was significantly (p < 0.001) lower than the mean motion amplitude of CAM measured from the proximal part of the artery (14.3mm, range 3.0-25.0) or from the distal part of the artery (14.4 mm, range 1.2-26.6). There was no significant difference between the amplitudes at these two sites of the circumflex artery.

It was found that the ratio between CAM and the end-diastolic length of the ventricle, which can be denominated fractional shortening in the long axis (FSL), was a better index of LV systolic function than CAM amplitude per se. There was a significant linear correlation between EF obtained by LV angiography and FSL (r = 0.81, SEE = 8.2, p < 0.001).

A power regression model had the best correlation between EF and FS_L. In this model the correlation between EF and FS_L can be described by the equation EF(%) = 19.2 x FS_L(%)^0.45 (R = 0.86, SEE = 0.14, p < 0.001). When values of FS_L ≥ 10% were selected to define a normal EF (≥ 50%) there was a sensitivity of 95% and a specificity of 93%.

Visual estimation of EF from assessment of CAM was not as good as the use of calculated FS_L but may be useful as fast screening method when classifying normal or impaired LV function.

In the fourth study, including 72 patients from the previous third study, who were referred for coronary and LV angiography, the systolic and diastolic parameters of CAM were measured by M-mode from coronary angiography. There were no significant difference between M-mode measures of CAM amplitude and calculated FS_L compared to the manually measured CAM amplitude and calculated FS_L.

The mean maximal systolic velocity of CAM was 70.1 mm/s (SD 21.8, range 17.6-139.0). When values ≥ 54 mm/s, a limit previously reported from an echocardiographic study (tissue Doppler of MAM), were selected to define a normal EF (≥ 50%) the sensitivity was 84.6% and specificity 94.6%.

A subgroup of 23 patients (17 had EF ≥ 50%) were examined by echocardiographic M-mode of MAM, within 24 h before the angiographic examination, for comparison of amplitudes and velocities measured by angiographic M-mode of CAM.

The total amplitude of CAM was significantly higher (p < 0.001) higher than the amplitude of MAM and so was the amplitude due to atrial contraction (p < 0.001).

The maximal systolic velocity of CAM was significantly (p < 0.001) higher than the corresponding velocity of MAM. The early maximal diastolic velocity of CAM was also significantly higher (p < 0.05) than the corresponding velocity of MAM. There was no significant difference between the late maximal diastolic velocity of CAM and the late diastolic velocity of MAM.

In summary, the systolic and diastolic phases of CAM, and thereby also the systolic and diastolic LV function, are well monitored by the angiographic M-mode method. The systolic indices arc CAM amplitude, FS_L and maximal systolic velocity of CAM. The diastolic indices are maximal early diastolic velocity of CAM and the amplitude due to atrial contraction.

The amplitudes and velocities of CAM are higher than the corresponding values for MAM in patients with normal EF. Therefore it is obvious that reference values of MAM and CAM amplitudes and velocities cannot be used interchangeably.

We have performed a study of 137 consecutive patients with thunderclap headache (TCH), showing that a large majority of the patients do not have a subarachnoidal haemorrhage (SAH). It is concluded that 11% of all TCH is caused by SAH and that history and findings in the clinical neurological examination cannot discriminate safely between an SAH and a more benign cause. All patients should be investigated with a CT scan and an analyses of the cerebrospinal fluid to exclude a SAH if the CT scan did not show an SAH. The 10-year follow-up showed that none of the patients with TH without SAH had a cerebral haemorrhage of any kind. Pathological results on CT and CSF examinations were found in 14 of the patients with non-SAH TCH, including five with cerebral infarction, three with intracerebral haemorrhage, four with aseptic meningitis and one with venous sinus thrombosis.

A case of Kleine-Levin syndrome with typical periodic hypersomnia and bulemia was diagnosed. On examination with single photo emission tomography (SPECT) (CERETEC«) during a relapse period and 2 weeks later there was marked cortical hypoperfusion of the frontal and temporal lobes, especially on the left side as well as in the right parietal lobe. Neuropsychological testing performed 1 week after a relapse showed a reduction in encoding to memory function of verbal learning indicating neocortical damage of the left fronto-temporal region. A follow-up 2 months later after the patient had spontaneously recovered showed only a slight left fronto-temporal disturbance. CT and MRI of the brain were normal although the MRI showed a large and asymmetric mamillary body. Neuropsychological testing 6 years after recovery showed pronounced reduction in short-time verbal and visual memory. Seven years after recovery SPECT demonstrated a normalized frontal perfusion but still a slight hypoperfusion in the left temporal lobe. Our results correlate to autopsy findings in two cases described previously.