Neonatal intracranial haemorrhage secondary to vein of Galen aneurysmal dilatation.

Paediatric neurovascular anomalies associated with the vein of Galen (VG) comprise of a spectrum of rare, complex, and life-threatening conditions. In this group, the "vein of Galen aneurysmal dilatation" (VGAD) is a distinct entity that often presents with progressive neurological symptoms in older children. Acute haemorrhage in VGAD is uncommon. We present an unusual presentation of VGAD in a neonate and discuss the challenges faced in the management.

Optic Nerve Tortuosity and Globe Proptosis in Normal and Glaucoma Subjects.

PRéCIS:: Eyes with glaucoma have tauter optic nerves compared with normal eyes, which may exert more force on the optic nerve head tissues during eye movements. PURPOSE: The purpose of this study was to assess the difference in optic nerve tortuosity during eye movements and globe proptosis between primary open angle glaucoma and normal subjects using orbital magnetic resonance imaging (MRI). METHODS: Ten Chinese subjects matched for ethnicity and refractive errors were recruited, including 5 normal controls and 5 patients with primary open angle glaucoma. All subjects underwent MRI to assess their optic nerves and globes for 3 eye positions: primary gaze, adduction, and abduction. Optic nerve tortuosity (optic nerve length divided by the distance between 2 ends) and globe proptosis (maximum distance between the cornea and interzygomatic line) were measured from MRI images. RESULTS: In adduction, the tortuosity of normal eyes was significantly larger than that of the glaucomatous eyes. Optic nerve tortuosity in adduction in the control and glaucoma groups were 1.004±0.003 (mean±SD) and 1.001±0.001, respectively (P=0.037). Globe proptosis (primary gaze) in glaucoma subjects (19.14±2.11 mm) was significantly higher than that in control subjects (15.32±2.79 mm; P=0.046). CONCLUSIONS: In this sample, subjects with glaucoma exhibited tauter optic nerves and more protruding eye globes compared with normal eyes. This may impact optic nerve head deformations in anatomically predisposed patients.

Competency-based Radiology Residency: A Survey of Expectations from Singapore's Perspective.

In response to the demands of an ageing nation, the postgraduate medical education in Singapore is currently in the early stage of transition into the American-styled residency programme. This study assessed the expectations of both radiology trainees and faculty on their ideal clinical learning environment (CLE) which facilitates the programme development. A modified 23-item questionnaire was administered to both trainees and faculty at a local training hospital. All items were scored according to their envisioned level of importance and categorised into 5 main CLE domains-supervision, formal training programme, work-based learning, social atmosphere and workload. 'Supervision' was identified as the most important domain of the CLE by both trainees and faculty, followed by 'formal training programmes', 'work-based learning' and 'social atmosphere'. 'Workload' was rated as the least important domain. For all domains, the reported expectation between both trainees and faculty respondents did not differ significantly. Intragroup comparison also showed no significant difference within each group of respondents. This study has provided valuable insights on both respondents' expectations on their ideal CLE that can best train competency in future radiologists. Various approaches to address these concerns were also discussed. The similarities in findings between ours and previous studies suggest that the 'supervision', 'formal training programmes' and 'work-based learning' domains are crucial for the success of a postgraduate medical training and should be emphasised in future curriculum. 'Workload' remains a challenge in postgraduate medical training, but attempts to address this will have an impact in future radiology training.

The MERCI Retrieval System for the management of acute ischaemic stroke--the NNI Singapore experience.

INTRODUCTION: Systemic and local intra-arterial thrombolysis in patients with large vessel ischaemic stroke is hampered by poor re-canalisation rates and risk of haemorrhage. The Merci Retrieval System is an endovascular device for removal of acute intracranial thrombus. We present our initial experience using this device in conjunction with existing thrombolytic therapy already in place in our institute. MATERIALS AND METHODS: Prospective data in all patients presenting with large vessel ischaemic stroke treated using the Merci Retrieval System from July 2007 to March 2009 were analysed. Selection criteria for patients were similar to the multi- Merci trial of 2008. We compared re-canalisation rate, National Institutes of Health Stroke Score (NIHSS) and modified Rankin score (mRS) outcomes to the published trial results. RESULTS: Seventeen patients were reviewed; none suffered immediate post-procedural complications. Fifteen underwent successful thrombus retrieval but in 2 cases the device failed due to technical considerations. Sites of vascular occlusion included: ICA/ICA-'T' junctions 27%, middle cerebral artery 13% and vertebrobasilar artery 60%. Of the 15 patients treated by MERCI with or without adjuvant thrombolytic therapy, complete re-canalisation was achieved in 60%, partial re-canalisation in 20%, partial re-canalisation with persistent distal vessel occlusion in 6% and failure of re-canalisation in 14%. Asymptomatic haemorrhage occurred in 33% and there was 1 death (6%) from symptomatic haemorrhage. Pre-treatment median NIHSS was 17.88 and 9.5 immediately post-treatment. Median mRS at 30 days was 2.6 for patients who achieved complete re-canalisation and 4.5 in failure or partial re-canalisation with or without persistent distal vessel occlusion. CONCLUSION: Re-canalisation rates using the Merci Retrieval System was comparable to the multi-Merci trial. Haemorrhagic complications and safety were also found to be satisfactory. Importantly, treatment success with eventual good clinical outcome hinges strongly on the ability of the device to achieve complete re-canalisation.

Stent-assisted percutaneous angioplasty for extra-cranial carotid disease:experience at Singapore General Hospital.

INTRODUCTION: This study aims to analyse the results of carotid stenting in a tertiary referral centre in Singapore. MATERIALS AND METHODS: Retrospective analysis of all carotid artery stenting (CAS) cases in a single centre from March 1997 to December 2008 was performed. Sixty successful procedures were performed in 61 patients, with bilateral stenting in 1 patient, and 2 failed procedures. The majority were Chinese (78.7%) and males (77.0%), with a high proportion having hypertension (82.0%) and hypercholesterolaemia (78.7%). The majority (91.8%) of patients were high surgical risk candidates, primarily due to cardiac risk factors. Ten patients (16.4%) had prior neck irradiation for nasopharyngeal carcinoma, and 3 patients each (4.9%) had previous endarterectomy and contralateral occlusion. A distal embolic protection device was used in 71.7% of cases. RESULTS: Technical success was 96.8%. The 30-day stroke and death rate was 13.8%, comparable to reported results for this high surgical risk population. CONCLUSION: CAS is a technically feasible and a relatively safe alternative to endarterectomy to treat extracranial carotid stenosis, especially in patients who are inoperable or at high surgical risk.

Clinical functional magnetic resonance imaging for pre-surgical planning--the Singapore General Hospital experience with the first 30 patients.

INTRODUCTION: Functional magnetic resonance imaging (fMRI) is a neuroradiological technique for the localisation of cortical function. FMRI made its debut in cognitive neuroscience and then eventually to other clinical applications. We report our experience with pre-surgical fMRI on a high field scanner, based purely on a clinical platform. MATERIALS AND METHODS: The protocols included motor, auditory, visual and language fMRI. The choice of protocols was dependant on clinical request and lesion locale. RESULTS: Retrospective analysis and audit of the fi rst 30 consecutive patients over a 12-month period revealed that about 85% of patients had a successful examination. In a pictorial essay, we demonstrate that patients with weakness in performing a motor task showed abnormal activations of the pre-motor and supplementary motor areas. CONCLUSION: FMRI data greatly enhances the pre-surgical planning process and the conduct of surgery when it is incorporated into the surgical navigation system in the operating theatre.

Idiopathic normal pressure hydrocephalus: correlating magnetic resonance imaging biomarkers with clinical response.

Idiopathic Normal Pressure Hydrocephalus (NPH) is a debilitating condition of the elderly. The patient is typically "wet, wobbly and wonky", to different degrees of the triad. The diagnosis is supported by the radiologic finding of dilated ventricles, determined by an elevated Evan's Index (EI) without a demonstrable cause. Patients with newly diagnosed NPH typically respond to ventriculo-peritoneal shunting (VPS). NPH-related dementia is possibly the only surgically reversible dementia. An elevated cerebrospinal fluid (CSF) fl ow rate (FR) is associated with a positive response to shunting. However, post-shunting EI and FRs are unpredictable. Of late, intracranial apparent diffusion coefficient (ADC) quantification via Diffusion Weighted Imaging (DWI) has been emerging as a possible marker in NPH diagnosis. A local study, conducted on a national level, to study the relationship of EI, FR and ADC to pre- and post-shunt clinical measurements has just ended. This review seeks to reconcile the current thinking of NPH, magnetic resonance imaging (MRI) quantification and clinical evaluation, and in the process shed some light on major pathophysiological determinants of the disease.

Dual Energy CT and its use in neuroangiography.

The dual energy CT (DECT) technology has been recently employed in the form of two X-ray sources of different energies to enhance the contrast between adjacent structures. Its use in the cardiac arena has been widely highlighted due to the higher temporal resolution. However, it may also be used in the craniocervical and peripheral vasculature for better differentiation between contrast-enhanced vascular lumina and calcified plaques, in the characterisation of ureteric stones, and in the evaluation of hepatic lesions. The objective of this paper is to revisit DECT physics, review the literature and discuss its use in CT neuroangiography with case illustrations from our institution, and impact on dose savings.

Vertebrae adjacent to spinal bone lesion are inconsistent reference markers: a magnetic resonance spectroscopic viewpoint.

PURPOSE: To ascertain the suitability of vertebrae adjacent to spinal bone lesions as a signal intensity reference on MRI, and compare the MR spectroscopic appearance of vertebral body compression fractures due to malignant tumor infiltration, bone weakening (e.g., osteoporosis), and/or minor trauma. MATERIALS AND METHODS: Twenty-five patients with spinal compression fractures underwent routine spinal MRI with an additional 1H MRS study protocol to assess the percent fat fraction of the compressed vertebrae as well as the adjacent bony environment. Peak areas for water and total lipid were calculated from short-TE single-voxel 1H MR spectra using the LCModel analyzing tool. RESULTS: There were consistent water-only patterns in the fractured vertebra suggesting either near complete marrow replacement by malignant tissue or local edematous fluid/hemorrhage within the marrow spaces. However, the adjacent vertebrae showed a wide range of patterns from a dominant lipid signal to the inverse of a pronounced water level. These results far exceed the normal variation expected based on age and sex. CONCLUSION: The results suggest that the adjacent vertebrae may not be an accurate reference, especially in diffusion-weighted imaging (DWI), because of the large difference between the two compartments. Furthermore, in the case of gradient-echo measurements, the in-phase vs. opposed-phase effects are significant.

Phonological processing in Chinese-English bilingual biscriptals: an fMRI study.

Different activation loci have been reported for language processing in unilingual Chinese and unilingual English participants, as well as in bilingual readers of English and French, two alphabetic languages. Nevertheless, the extant imaging work on Mandarin-English bilinguals favors common neural substrates for English and Chinese, languages with contrasting oral and written forms. We investigated the phonological processes in reading for English-Chinese biscriptals using a homophone matching task with parallel behavioral (n = 28) and fMRI (n = 6) experiments. Unlike previous reports, we observed distinct regions of activation for Mandarin in the left and right frontal lobes, the left temporal lobe, and the right occipital lobe, plus distinct regions of activation for English bilaterally in both the frontal and parietal lobes. The implications of these novel findings are discussed with reference to language representation in bilinguals.

Is your interventional radiology service ready for SARS?: The Singapore experience.

The recent epidemic of severe acute respiratory syndrome caught many by surprise. Hitherto, infection control has not been in the forefront of radiological practice. Many interventional radiology (IR) services are therefore not equipped to deal with such a disease. In this review, we share our experience from the interventional radiologist's perspective, report on the acute measures instituted within our departments and explore the long-term effects of such a disease on the practice of IR.

Concomitant diminishing magnetization-transfer effect and increasing choline level in radiation-induced temporal-lobe changes.

This article reports on the use of both magnetization-transfer (MT) imaging and 1H-MR spectroscopy in two cases of bilateral temporal-lobe changes after radiation therapy for nasopharyngeal carcinoma. In the first case, the following patterns were noted: (i) although the temporal lobes appeared relatively normal on T2-weighted MR imaging, corresponding MT imaging clearly showed signal abnormalities (decreased MT effect) consistent with alterations in macromolecular structure; and (ii) concomitant strongly elevated choline on 1H-MR spectroscopy was observed, and this is associated with metabolic changes in cell membranes. The second case presented similar characteristics. In addition, there was an increased lactate signal and T2 signal changes in keeping with established oedema. Both MT and proton-spectroscopic findings were consistent with postulated pathophysiological features of radiation injury, but their specificity for this condition remains unclear. Magnetization-transfer imaging, and possibly 1H-MR spectroscopy, might be sensitive techniques for the early detection of late radiation injury.