Gray Matter Changes Following Mild COVID-19: An MR Morphometric Study in Healthy Young People.

BACKGROUND: Although COVID-19 is primarily an acute respiratory infection, 5%-40% of patients develop late and prolonged symptoms with frequent neurological complaints, known as long COVID syndrome. The presentation of the disease suggests that COVID infection may cause functional and/or morphological central nervous system alterations, but studies published in the literature report contradictory findings. PURPOSE: To investigate the chronic effects of COVID-19 on cerebral grey matter in a group of young patients without comorbidities, with mild course of COVID infection and no medical complaints at the time of examination. STUDY TYPE: Prospective. POPULATION: Thirty-eight young (age = 26.6 ± 5.0 years; male/female = 14/24), adult participants who recovered from mild COVID infection without a history of clinical long COVID and 37 healthy control subjects (age = 25.9 ± 2.8 years; male/female = 14/23). FIELD STRENGTH/SEQUENCE: Three Tesla, 3D T1-weighted magnetization-prepared rapid gradient-echo, 2D T2-weighted turbo spin-echo. ASSESSMENT: MRI-based morphometry and volumetry along with neuropsychological testing and self-assessed questionnaire. STATISTICAL TESTS: Fisher's exact test, Mann-Whitney U-test, and multiple linear regression analyses were used to assess differences between COVID and healthy control groups. P < 0.05 was used as cutoff for significance. RESULTS: In the COVID group, significantly lower bilateral mean cortical thickness (left/right-hemisphere: 2.51 ± 0.06 mm vs. 2.56 ± 0.07 mm, η2 p = 0.102/2.50 ± 0.06 mm vs. 2.54 ± 0.07 mm, η2 p = 0.101), lower subcortical gray matter (57881 ± 3998 mm3 vs. 60470 ± 5211 mm3 , η2 p = 0.100) and lower right olfactory bulb volume (52.28 ± 13.55 mm3 vs. 60.98 ± 15.8 mm3 , η2 p = 0.078) were found. In patients with moderate to severe anosmia, cortical thickness was significantly lower bilaterally, as compared to patients without olfactory function loss (left/right-hemisphere: 2.50 ± 0.06 mm vs. 2.56 ± 0.05 mm, η2 = 0.173/2.49 ± 0.06 mm vs. 2.55 ± 0.05 mm, η2 = 0.189). Using further exploratory analysis, significantly reduced cortical thickness was detected locally in the right lateral orbitofrontal cortex in the COVID group (2.53 ± 0.10 mm vs. 2.60 ± 0.09 mm, η2 p = 0.112). DATA CONCLUSION: Even without any subjective or objective neurological complaints at the time of the MR scan, subjects in the COVID group showed gray matter alterations in cortical thickness and subcortical gray matter volume. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 3.

[Minimally invasive and O-arm assisted en bloc spinal tumor resections]. / Minimálisan invazív és O-arm asszisztált en bloc gerincdaganat-reszekciók.

BACKGROUND AND PURPOSE: The en bloc resection of spinal tumors is required in primary spine tumors and in selected cases of secondary spine tumors, where the primary disease is under control and long survival time is expected. Three cases are presented, applying O-arm assisted navigation or minimally invasive anterior approaches for en bloc tumor removal. METHODS: O-arm navigation assisted osteotomies were carried out to remove a Th.V. breast tumor metastasis en bloc, intact bony part of the Th.V. vertebra was spared. Vertebral corpectomies of a patient with L.IV. chordoma and of a patient with L.V. carcinoid were also performed using minimally invasive, microscope assisted, anterior approaches to the lumbar spine. RESULTS: No morbidity or local recurrence were detected in the patient with breast cancer 1 year after the operation. Nevertheless, new spinal metastasis were revealed 1 year after surgery despite the appropriate oncological treatment. The patient with L.IV. chordoma is still tumor free (last follow-up: 18 month after surgery), but post operatively detected lower limb paresis and gait disturbances are persisted. The posterior healthy bony parts of the spinal column remained intact, since only anterior approaches were used for en bloc L.IV. corpectomy. No morbidity or recurrence was detected in patient with L.V. carcinoid tumor on 1 year follow-up. CONCLUSION: Both the O-arm navigation assisted surgery and the minimally invasive anterior approaches to the spine can help to reduce surgical morbidity and to spare healthy bony structures of the spine. The later could play important role to provide long term spine stability. The presented new surgical technologies can be accepted only, if they produce at least the same oncological results on longer follow-ups as conventional surgical approaches.

The role of hybrid FDG-PET/MRI on decision-making in presurgical evaluation of drug-resistant epilepsy.

BACKGROUND: When MRI fails to detect a potentially epileptogenic lesion, the chance of a favorable outcome after epilepsy surgery becomes significantly lower (from 60 to 90% to 20-65%). Hybrid FDG-PET/MRI may provide additional information for identifying the epileptogenic zone. We aimed to investigate the possible effect of the introduction of hybrid FDG-PET/MRI into the algorithm of the decision-making in both lesional and non-lesional drug-resistant epileptic patients. METHODS: In a prospective study of patients suffering from drug-resistant focal epilepsy, 30 nonlesional and 30 lesional cases with discordant presurgical results were evaluated using hybrid FDG-PET/MRI. RESULTS: The hybrid imaging revealed morphological lesion in 18 patients and glucose hypometabolism in 29 patients within the nonlesional group. In the MRI positive group, 4 patients were found to be nonlesional, and in 9 patients at least one more epileptogenic lesion was discovered, while in another 17 cases the original lesion was confirmed by means of hybrid FDG-PET/MRI. As to the therapeutic decision-making, these results helped to indicate resective surgery instead of intracranial EEG (iEEG) monitoring in 2 cases, to avoid any further invasive diagnostic procedures in 7 patients, and to refer 21 patients for iEEG in the nonlesional group. Hybrid FDG-PET/MRI has also significantly changed the original therapeutic plans in the lesional group. Prior to the hybrid imaging, a resective surgery was considered in 3 patients, and iEEG was planned in 27 patients. However, 3 patients became eligible for resective surgery, 6 patients proved to be inoperable instead of iEEG, and 18 cases remained candidates for iEEG due to the hybrid FDG-PET/MRI. Two patients remained candidates for resective surgery and one patient became not eligible for any further invasive intervention. CONCLUSIONS: The results of hybrid FDG-PET/MRI significantly altered the original plans in 19 of 60 cases. The introduction of hybrid FDG-PET/MRI into the presurgical evaluation process had a potential modifying effect on clinical decision-making. TRIAL REGISTRATION: Trial registry: Scientific Research Ethics Committee of the Medical Research Council of Hungary. TRIAL REGISTRATION NUMBER: 008899/2016/OTIG . Date of registration: 08 February 2016.

Cost-effectiveness analysis of invasive EEG monitoring in drug-resistant epilepsy.

PURPOSE: Our aim was to determine the cost-effectiveness of two intracranial electroencephalography (iEEG) interventions: 1) stereoelectroencephalography (SEEG) and 2) placement of subdural grid electrodes (SDGs) both followed by resective surgery in patients with drug-resistant, partial-onset epilepsy, compared with medical management (MM) in Hungary from payer's perspective. METHODS: The incremental health gains and costs of iEEG interventions have been determined with a combination of a decision tree and prevalence Markov process model over a 30-year time horizon in a cost-utility analysis (CUA). To address the effect of parameter uncertainty on the incremental cost-effectiveness ratio (ICER), deterministic and probabilistic sensitivity analyses were performed. RESULTS: Our results showed that both SEEG and SDG interventions represent a more expensive but more effective strategy than MM representing the current standard of care. The total discounted cost of SEEG and SDG were € 32,760 and € 25,028 representing € 18,108 and € 10,375 additional cost compared with MM, respectively. However, they provide an additional 3.931 (in SEEG group) and 3.444 quality-adjusted life years (QALYs; in SDG group), correspondingly. Thus, the ICER of SEEG is € 4607 per QALY gain, while the ICER for SDG is € 3013 per QALY gain, compared with MM. At a cost-effectiveness threshold of € 41,058 per QALY in Hungary, both subtypes of iEEG interventions are cost-effective and provide good value for money. SIGNIFICANCE: Because of the high cost of implanting electrodes and monitoring, the invasive EEG for patients with refractory epilepsy is currently not available in the Hungarian national healthcare system. Our study demonstrated that these procedures in Hungary are cost-effective compared with the MM. As a result, the introduction of iEEG interventions to the reimbursement list of the National Health Insurance Fund Administration was initiated.

Detection of silent cerebral microcirculatory abnormalities in patients with manifest ischemic coronary disease: a perfusion brain MRI study combined with dipyridamole stress.

OBJECTIVES: Intravenous dipyridamole (DP) can induce transient perfusion abnormalities in the heart but also the brain indicated by brain SPECT. L-arginine can regulate the vascular tone via nitric oxide (NO). Therefore, we examined cerebral blood volume (CBV) by perfusion MRI and L-arginine level before and after DP stress in patients, who developed transient neurological signs, and compared these to unaffected patients. DESIGN: A total of nine patients with ischemic coronary disease after myocardial perfusion scintigraphy were selected for this prospective pilot study. Four had DP-induced transient mild neurologic signs during myocardial perfusion scintigraphy, while five had no neurological signs. By using perfusion MRI in both groups in a second stage, we examined CBV in identical areas of the two hemispheres before and during DP stress. Besides, pre-and post-stress L-arginine serum levels were also analyzed by high-performance liquid chromatography. Trial registration: NCT03688815. RESULTS: CBV in the sensory-motor area at baseline was significantly higher in patients with DP-induced transient neurological signs compared to patients without signs (p = 0.028). Intravenous DP normalized the higher perfusion by decreasing CBV, and also increased serum L-arginine level (p = 0.001). CONCLUSIONS: Intravenous DP changed the CBV accompanied by a systemic elevation of L-arginine: this indicates a direct vasorelaxing effect on brain vessels, and an indirect vasodilator effect through L-arginine release presumably via NO. In areas with decreased CBV before DP, such double effects caused transient neurological symptoms presumably due to steal phenomenon. Therefore, intravenous DP may have a potential to identify patients with high risk for cerebral ischemia.

Criterion validity and reliability of the International Physical Activity Questionnaire - Hungarian short form against the RM42 accelerometer.

BACKGROUND: Physical inactivity is a global phenomenon in European welfare countries. Proper monitoring is essential to measure the physical activity level of the population. METHODS: In the Hungarian cohort of the European Physical Activity and Sport Monitoring System (EUPASMOS) project, our participants (N = 598) completed sociodemographic questions and the International Physical Activity Questionnaire - short form (IPAQ-SF) survey. The validity and reliability of the subjective measurement tool were examined, IPAQ-SF outcomes were contrasted against triaxial RM42 accelerometer wore for 7 consecutive days. RESULTS: The IPAQ-SF showed moderate internal consistency (Cronbach Alpha = 0.647). The concurrent validity of the IPAQ-SF to triaxial accelerometer indicated a significant weak-to-moderate correlation (R = 0.111-0.338, p = 0.042; p < 0.001). The test-retest reliability showed a significant correlation between two measurements (R = 0.788-0.981, p < 0.001). CONCLUSION: The Hungarian version of the IPAQ-SF had excellent test-retest reliability, but low-to-fair concurrent validity for moderate and vigorous physical activity, walking and sitting time, as compared to the objective criterion measure among Hungarian adults.

[Minimally invasive, extrapleural-anterolateral approach to the spine]. / Minimálisan invazív, extrapleuralis, anterolateralis gerincfeltárás.

In spine surgery, minimally invasive approaches (MIS) are getting accepted and more popular worldwide during the last decades. It is due to the reduced intraoperative blood loss, decreased infection rate, less postoperative pain and earlier discharge from hospital compared to traditional approaches. The present paper puts forward a minimally invasive extrapleural approach to the thoracic spine that is not applied in Hungary. This new approach, in contrast to the standard costotransversectomy, provides direct visual control over the ventral surface of the dural sac. Furthermore, contrary to the transthoracic way, following minimally invasive extrapleural surgery thoracic drainage and intensive care are not necessary. The approach can be applied safely in treatment of ventral or ventrolateral pathologies of the thoracic spine.

How Efficient Is Subthalamic Deep Brain Stimulation in Reducing Dyskinesia in Parkinson's Disease?

BACKGROUND: Dyskinesia is among the most troublesome symptoms of advanced Parkinson's disease (PD). The recently developed Unified Dyskinesia Rating Scale (UDysRS) can simultaneously measure several subjective and objective aspects of dyskinesia, irrespective of the other motor symptoms of PD. Despite the advantages of deep brain stimulation (DBS), previous studies on DBS have not used the UDysRS yet. METHODS: In this prospective study, 71 consecutive patients undergoing DBS implantation were enrolled. Patients were examined twice: 1 week prior to the DBS implantation (baseline) and 12 months postoperatively. The severity of PD-related symptoms was assessed by the Movement Disorders Society Unified PD Rating Scale (MDS-UPDRS). The presence and severity of dyskinesia were specifically measured by the UDysRS and patient diaries. RESULTS: At baseline, all 71 patients had dyskinesia, but 1 year after DBS implantation, 25 patients were dyskinesia-free, and an additional 19 had only mild dyskinesia. The total score on the UDysRS decreased from 38.0 ± 17.8 to 10.8 ± 13.0 (p < 0.001). Besides this, all parts of the UDysRS showed significant improvement after STN DBS treatment, and the magnitude of these changes had a large effect size. The total score of MDS-UPDRS improved from 76.5 ± 24.3 to 60.4 ± 21.4 points (p < 0.001). CONCLUSIONS: Based on our results, UDysRS can reliably detect improvements in dyskinesia after DBS implantation.

In vivo detection of hyperacute neuronal compaction and recovery by MRI following electric trauma in rats.

PURPOSE: To verify the following phenomenon in vivo using quantitative magnetic resonance imaging (MRI). Neuronal compression may occur following brain injuries in the cortex and hippocampus. As well being characterized by previous histological studies in rats, the majority of these neurons undergo hyperacute recovery rather than apoptotic death. MATERIALS AND METHODS: Twenty male Wistar rats were assigned into injured or sham-injured groups (n = 10). The injured group underwent an electric trauma model to provoke compacted neuron formation. A T1 map was acquired prior to the injury and 10 T1 maps were acquired consecutively over a period of 2.5 hours after the injury, using a 3.0T scanner. Voxelwise statistical analyses were performed between timepoints. To enable comparison with the histological appearance of the compacted neurons, silver staining was performed on a sham-injured rat and five injured rats, 10, 40, 90, 150, and 300 minutes after the injury. RESULTS: A significant (corrected P < 0.05) increase in average T1 from the preinjury (895.24 msec) to the first postinjury timepoint (T1 = 951.37 msec) was followed by a significant (corrected P < 0.05) decrease (return) up to the last postinjury timepoint (T1 = 913.16 msec) in the voxels of the cortex and hippocampus. No significant (corrected P < 0.05) change in T1 was found in the sham-injured group. CONCLUSION: The spatial and temporal linkages between the MRI T1 changes and the histological findings suggest that neuronal compaction and recovery is associated with T1 alterations. MRI therefore offers the possibility of in vivo investigations of neuronal compaction and recovery. J. MAGN. RESON. IMAGING 2016;44:814-822.

Biexponential diffusion alterations in the normal-appearing white matter of glioma patients might indicate the presence of global vasogenic edema.

PURPOSE: To investigate normal-appearing white matter (NAWM) microstructure of glioma patients with biexponential diffusion analysis in order to reveal the nature of diffusion abnormalities and to assess whether they are region-specific or global. MATERIALS AND METHODS: Twenty-four newly diagnosed glioma patients (grade II-IV) and 24 matched control subjects underwent diffusion-weighted imaging at 3T. Diffusion parameters were calculated using monoexponential and biexponential models. Apparent diffusion coefficient (ADC) values were measured in the entire NAWM of the hemisphere contralateral and ipsilateral to the tumor. In the contralateral NAWM, regional ADC values were assessed in the frontal, parietal, occipital, and temporal NAWM. RESULTS: ADCmono and ADCfast were significantly higher than control values in all investigated regions except the temporal NAWM (P < 0.04). ADCslow was significantly increased in the total contralateral, frontal, and parietal NAWM (P < 0.03), while pslow was decreased in both total hemispheric NAWM and the parietal NAWM of glioma patients compared to controls (P < 0.04). ADCmono , ADCfast , ADCslow , and pslow were significantly different among the NAWM of the four lobes of the contralateral hemisphere in both groups (P < 0.0001), and these regional differences were similar in patients and controls (P > 0.05). Hemispheric ADCmono and pslow differences were different between groups (P < 0.05). CONCLUSION: Globally altered diffusion parameters suggest the presence of global vasogenic edema in the NAWM of glioma patients, which is further supported by the finding that regional differences in patients follow those found in controls. Alternatively, some tumor infiltration might contribute to diffusion abnormalities in the NAWM, especially in the tumor-affected hemisphere. J. Magn. Reson. Imaging 2016;44:633-641.

Increased diffusion in the normal appearing white matter of brain tumor patients: is this just tumor infiltration?

Altered diffusion in the normal appearing white matter (NAWM) of glioma patients has been explained by tumor infiltration. The goal of the present study was to test this explanation indirectly by examining whether these alterations were also present in the contralateral NAWM of non-infiltrative tumors like meningiomas; and to search for other possible reasons for this abnormality. Twenty-seven patients with histologically verified glioma (grade II-IV), 22 meningioma patients and two groups of age- and sex-matched healthy controls underwent diffusion weighted imaging (DWI) on a 3T MR. All patients were examined before treatment. Apparent diffusion coefficient (ADC) values were calculated in the entire NAWM of the hemisphere contralateral to the tumor. ADC values of the NAWM were compared between groups with Mann-Whitney U-test and multiple linear regression. The relations of ADC in NAWM to glioma grade and to tumor volume were also investigated. ADC values of the contralateral NAWM were significantly higher in both glioma and meningioma patients compared to controls (P = 0.0006 and 0.0099, respectively). ADC value was higher in the NAWM of high grade gliomas than in low grade gliomas (P = 0.0181) and in healthy control subjects (P = 0.0003). ADC did not depend on tumor volume in any of the patient groups. Elevated ADC in the NAWM of both glioma and meningioma patients might indicate that the effect of infiltrating tumor cells is not the only reason for the alteration as it has been previously suggested. Although the role of mass effect was not proved, other mechanisms might also contribute to ADC elevation.

Age at onset and seizure frequency affect white matter diffusion coefficient in patients with mesial temporal lobe epilepsy.

In mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS), structural abnormalities are present not only in the hippocampus but also in the white matter with ipsilateral predominance. Although the timing of epilepsy onset is commonly associated with clinical and semiological dissimilarities, limited data exist regarding white matter diffusion changes with respect to age at epilepsy onset. The aim of this study was to investigate diffusion changes in the white matter of patients with unilateral MTLE-HS with respect to clinical parameters and to compare them with an age- and sex-matched healthy control group. Apparent diffusion coefficients (ADCs) were derived using monoexponential approaches from 22 (11 early and 11 late age at onset) patients with unilateral MTLE-HS and 22 age- and sex-matched control subjects after acquiring diffusion-weighted images on a 3T MRI system. Data were analyzed using two-tailed t-tests and multiple linear regression models. In the group with early onset MTLE-HS, ADC was significantly elevated in the ipsilateral hemispheric (p=0.04) and temporal lobe white matter (p=0.01) compared with that in controls. These differences were not detectable in late onset MTLE-HS patients. Apparent diffusion coefficient of the group with early onset MTLE-HS was negatively related to age at epilepsy onset in the ipsilateral hemispheric white matter (p=0.03) and the uncinate fasciculus (p=0.03), while in patients with late onset MTLE-HS, ADC was no longer dependent on age at epilepsy onset itself but rather on the seizure frequency in the ipsilateral uncinate fasciculus (p=0.03). Such diffusivity pattern has been associated with chronic white matter degeneration, reflecting myelin loss and higher extracellular volume which are more pronounced in the frontotemporal regions and also depend on clinical features. In the group with early onset MTLE-HS, the timing of epilepsy seems to be the major cause of white matter abnormalities while in late onset disease, it has a secondary role in provoking diffusion changes.

Differentiating white matter lesions in multiple sclerosis and migraine using monoexponential and biexponential diffusion measurements.

PURPOSE: To compare the white matter lesions seen in multiple sclerosis and migraine using monoexponential and high b-value biexponential diffusion measurements. MATERIALS AND METHODS: Diffusion-weighted images were acquired on a 3.0-Tesla magnetic resonance imaging system. Diffusion parameters were estimated using monoexponential (0-1000 s/mm(2) ) and biexponential (0-5000 s/mm(2) ) approaches from 15 multiple sclerosis patients, 15 patients with migraine and 15 healthy control subjects. The study was performed in accordance with the approval of the Regional Research Ethics Committee. The apparent diffusion coefficient (ADC) values were measured in the lesions and the normal-appearing white matter of patients and in the white matter of controls. RESULTS: High lesional ADCmono values were detected in both patient groups without significant differences between the groups (10.72 and 9.86 × 10(-4) mm(2) /s for MS and migraine respectively, P = 0.2134). The biexponential measurements showed significantly higher ADCfast , ADCslow , and Pslow values in the migraine lesions than in the multiple sclerosis lesions (16.47 versus 14.29, 1.41 versus 0.76, and 20.34 versus 12.01 all values in 10(-4) mm(2) /s; P = 0.0344, P = 0.0019, P = 0.0021, respectively). CONCLUSION: Biexponential diffusion analysis may help to differentiate multiple sclerosis-related white matter lesions from migraine-related ones.

Changes of migraine-related white matter hyperintensities after 3 years: a longitudinal MRI study.

OBJECTIVE/BACKGROUND: The aim of this longitudinal study was to investigate changes of migraine-related brain white matter hyperintensities 3 years after an initial study. Baseline quantitative magnetic resonance imaging (MRI) studies of migraine patients with hemispheric white matter hyperintensities performed in 2009 demonstrated signs of tissue damage within the hyperintensities. The hyperintensities appeared most frequently in the deep white matter of the frontal lobe with a similar average hyperintensity size in all hemispheric lobes. Since in this patient group the repeated migraine attacks were the only known risk factors for the development of white matter hyperintensities, the remeasurements of migraineurs after a 3-year long follow-up may show changes in the status of these structural abnormalities as the effects of the repeated headaches. METHODS: The same patient group was reinvestigated in 2012 using the same MRI scanner and acquisition protocol. MR measurements were performed on a 3.0-Tesla clinical MRI scanner. Beyond the routine T1-, T2-weighted, and fluid-attenuated inversion recovery imaging, diffusion and perfusion-weighted imaging, proton magnetic resonance spectroscopy, and T1 and T2 relaxation time measurements were also performed. Findings of the baseline and follow-up studies were compared with each other. RESULTS: The follow-up proton magnetic resonance spectroscopy studies of white matter hyperintensities showed significantly decreased N-acetyl-aspartate (median values 8.133 vs 7.153 mmol/L, P=.009) and creatine/phosphocreatine (median values 4.970 vs 4.641 mmol/L, P=.015) concentrations compared to the baseline, indicating a more severe axonal loss and glial hypocellularity with decreased intracellular energy production. The diffusion values, the T1 and T2 relaxation times, and the cerebral blood flow and volume measurements presented only mild changes between the studies. The number (median values 21 vs 25, P<.001) and volume (median values 0.896 vs 1.140 mL, P<.001) of hyperintensities were significantly higher in the follow-up study. No changes were found in the hemispheric and lobar distribution of hyperintensities. An increase in the hyperintensity size of preexisting lesions was much more common than a decrease (median values 14 vs 5, P=.004). A higher number of newly developed hyperintensities were detected than disappeared ones (130 vs 22), and most of them were small (<.034 mL). Small white matter hyperintensities in patients with a low migraine attack frequency had a higher chance to disappear than large white matter hyperintensities or white matter hyperintensities in patients with a high attack frequency (coefficient: -0.517, P=.034). CONCLUSIONS: This longitudinal MRI study found clinically silent brain white matter hyperintensities to be predominantly progressive in nature. The absence of a control group precludes definitive conclusions about the nature of these changes or if their degree is beyond normal aging.

[TREATMENT OF POST-SPONDYLODESIS, ADJACENT-SEGMENT DISEASE WITH MINIMALLY INVASIVE, ANTEROLATERAL SURGERY ON THE LUMBAR SPINE: IS THERE IS NO NEED FOR DORSAL OPERATION?]. / SPONDYLODESIST KÖVETOEN KIALAKULT SZOMSZÉDOS SZEGMENTUM BETEGSÉG MEGOLDÁSA MINIMÁLISAN INVAZÍV, ANTEROLATERALIS FELTÁRÁSBÓL A LUMBÁLIS GERINCSZAKASZON: NEM SZÜKSÉGES DORSALIS MUTÉT?

Adjacent segment disease (ASD) occurs with a probability of 30% in the lumbar spine following spinal fusion surgery. Usually advanced degenerative changes happen cranially to the fused lumbar segment. Thus, secondary spinal instability, stenosis, spodylolisthesis, foraminal stenosis can lead to the recurrence of the pain not always amenable to conservative measures. A typical surgical solution to treat ASD consists of posterior revision surgery including decompression, change or extension of the instrumentation and fusion to the rostral level. It results in a larger operation with considerable risk of complications. We present a typical case of ASD treated surgically with a new minimally invasive method not yet performed in Hungary. We use anterolateral abdominal muscle splitting approach to reach the lumbar spine through the retroperitoneum. A discectomy is performed by retracting the psoas muscle dorsally. The intervertebral bony fusion is achieved by implanting a cage with large volume that is stuffed with autologous bone or tricalcium phosphate. A cage with large volume results in excellent annulus fibrosus tension, immediate stability and provides large surface for bony fusion. A stand-alone cage construct can be supplemented with lateral screw/rod/plate fixation. The advantage of the new technique for the treatment of ASD includes minimal blood loss, short operation time, significantly less postoperative pain and much lower complication rate.

MULTIMODAL QUANTITATIVE CHARACTERIZATION OF INTRACRANIAL EPIDERMOID CYSTS: PRELIMINARY RESULTS.

BACKGROUND AND PURPOSE: The differentiation of epidermoid cysts from other intracranial lesions with CT and conventional MR imaging is challenging. The risk of residual and recurrent disease is high and multimodal imaging should therefore promote a precise differential diagnosis. Since epidermoid cysts are histologically identical to middle ear cholesteatomas, MRI methods that are useful in the diagnosis of cholesteatoma; specifically EPI DWI and a non-EPI diffusion subtype (HASTE DWI) may possibly be applicable to epidermoid cysts. Besides testing the diagnostic utility of these methods on epidermoid cysts, our goal was to quantify the T1 and T2 relaxation times, the ADC values and the magnetization transfer ratios in order to acquire objective, characteristic information about their structure and contents. Finally, our goal was to provide the physician with a reliable, multimodal diagnostic tool that supports accurate surgical planning. METHODS: Two patients with epidermoid cysts were examined. Besides the conventional MR scans EPI DWI, HASTE DWI, quantitative T1, T2 and magnetization transfer measurements were performed mappingwith a 3T MR scanner. After image registration, T1, T2 relaxation times and the magnetization transfer ratio inside a ROI were determined according to the lesion location on HASTE DWI. Mean ADC values inside the epidermoid cysts were also calculated by both mono-exponential and bi-exponential diffusion models. RESULTS: Our results revealed relatively high T1 and T2 relaxation times and ADC values, and low magnetization transfer ratios in both subjects. CONCLUSION: HASTE-DW MRI provides accurate morphologic information on epidermoid cysts, while T1, T2, ADC and magnetization transfer ratio maps are quantitative techniques. Thus the combination of these methods results in a confident preoperative diagnosis and aids to determine the indication of retreatment in the event of recurrence.

[NOVEL STRATEGY IN THE RADIOTHERAPY OF METASTATIC BRAIN TUMORS: SIMULTANEOUS WHOLE BRAIN RADIOTHERAPY AND INTEGRATED STEREOTACTIC RADIOSURGERY]. / ÚJ LEHETOSÉG AZ AGYI ÁTTÉTEK SUGÁRKEZELÉSÉBEN: EGYÜTTESEN ALKALMAZOTT TELJESKOPONYA-BESUGÁRZÁS ÉS INTEGRÁLT SZTEREOTAXIÁS SUGÁRSEBÉSZETI ELLÁTÁS.

BACKGROUND AND PURPOSE: Treatment of central nervous system (CNS) tumors has always played an important role in development of radiotherapy techniques. Precise patient immobilisation, non-coplanar field arrangement, conformal treatment, arc therapy, radiosurgery, application of image fusion to radiation planning or re-irradiation were first introduced into clinical routine in the treatment of brain tumors. METHODS: A modern multifunctional radiation instrument, Novalis TX has been installed at the University of Pécs two years ago. New methods, such as real time 3D image guided therapy, dynamic arc therapy and ultra-conformity offer further progress in treatment of CNS tumors. Whole brain irradiation and simultaneous fractionated stereotactic radiosurgery or integrated boost seem to be an optimal method in the treatment of not only soliter or oligo, but even a higher number (4-9) and not typically radiosensitive brain metastases. The new treatment strategy is illustrated by presentation of four case histories. RESULTS: Treatment protocol was completed in all cases. Treatment period of 1.5 to 3 weeks, and treatment time of only a few minutes were not stressful for the patients. A quite remarkable clinical improvement as to general condition of the patients was experienced in three cases. Follow-up images confirmed either remission or a stable disease. CONCLUSIONS: Simultaneous whole brain radiotherapy and integrated stereotactic radiosurgery is a reproducible, safe method that offers an effective irradiation with delivery of definitive dosage even in cases with radio-insensitive brain metastasis.

[EARLIER AND MORE EFFICIENTLY: THE ROLE OF DEEP BRAIN STIMULATION IN PARKINSON'S DISEASE: PRESERVING THE WORKING CAPABILITY]. / KORÁBBAN ÉS HATÉKONYABBAN: A MÉLY AGYI STIMULÁCIÓ SZEREPE A MUNKAKÉPESSÉG MEGORZÉSÉBEN.

BACKGROUND: The recently published "EarlyStim" study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients. METHODS: We reviewed the data of 39 young (< 60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pécs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job ("Job+" group, n = 15) and retired patients (without active job, "Job-" group, n = 24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation. RESULTS: As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p < 0.01, McNemar test). CONCLUSION: Although our retrospective study has several limitations, our results fit well with the conclusions of "EarlyStim" study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.

[HEALTH INSURANCE ASPECTS OF PHYSIOTHERAPEUTIC CARE OF NEUROLOGY DISORDERS IN OUTPATIENT CARE]. / A NEUROLÓGIAI KÓRKÉPEK FIZIOTERÁPIÁS ELLÁTÁSÁNAK EGÉSZSÉGBIZTOSÍTÁSI VONATKOZÁSAI A JÁRÓBETEG-SZAKELLÁTÁSBAN.

BACKGROUND AND PURPOSE: The aim of our study is to analyse the ambulatory rehabilitation care of patients with neurological disorders in the field of physiotherapy. METHODS: Data derive from the database of the Hungarian National Health Insurance Fund Administration (year 2009). The analyses covered patients with diagnosis "G00-G99 Diseases of the nervous system" according to the International Classification of Diseases and underwent physiotherapy treatment. RESULTS: In 2009 altogether 190986 patients with neurological disorders received physiotherapy treatment in outpatient care, representing 1331675 cases and got 388.215 million Hungarian Forint health insurance reimbursement. The number of patients with nerve, nerve root and plexus disorders was 39 patients/10 000 population for males and 66 patients/10000 population for females. The number of patients with cerebral palsy and other paralytic syndromes was 49 patients/10000 population for males and 35 patients/10000 population for females. The number of patients with episodic and paroxysmal disorders was 33 patients/10000 population for males and 52 patients/10000 population for females. CONCLUSION: In the outpatient physiotherapy care the utilization indicators for female patients were higher in nerve, nerve root and plexus disorders and episodic and paroxysmal disorders, while in cerebral palsy and other paralytic syndromes the utilization by male patients was higher. There are important age and gender inequalities in the utilization of physiotherapy care of patients with neurological disorders.

A miniature optical neuronavigation system for CT-guided stereotaxy.

BACKGROUND AND OBJECTIVE: Neuronavigation devices have progressed over the past 2 decades, but logistical limitations remain for many stereotactic procedures. We describe our technique and accuracy for a novel miniature optical tracking system which overcomes these limitations. METHOD: The minioptical tracking system uses a miniature video camera mounted on a rigid cannula to determine cannula location and orientation relative to a patient-attached sticker containing reference markers. A CT scan is used to register these markers to the anatomy and a user-selected target. A computer displays the cannula guidance information to the target. Bench testing was performed on 225 targets in a custom test phantom and additional testing was performed on 20 small targets in an anthropomorphic head phantom to determine the practical accuracy and workflow. RESULTS: The phantom study demonstrated that 3-D navigation accuracy is 1.41 ± 0.53 mm. There was a 100% head phantom study success rate for the 20 small targets. CONCLUSIONS: The resulting accuracy data demonstrated good correlation with the CT data, and the clinical simulation workflow indicated its potential usefulness for common neurosurgical applications. Furthermore, this small-footprint tracking technology does not experience the traditional environmentally induced issues or the requirement of pin-based head fixation, allowing for use in the neurointensive care unit and the emergency department.