Diagnosis and management of occult non-missile penetrating brain injury.

Penetrating brain injury (PBI) is a subtype of traumatic brain injury (TBI) that has been steadily increasing in prevalence and causing significant mortality in trauma patients. In an emergent setting, it is important to determine the mechanism of injury and decide whether a PBI or a blunt TBI has occurred in order to guide diagnostic imaging and subsequent treatment. In cases where a PBI has been likely or has occurred, it is important to initiate treatment expeditiously as rapid interventions have been shown to lead to better outcomes. However, in cases of unwitnessed pediatric trauma, it can be difficult to ascertain the specific method of injury due to a lack of reliable sources. In such cases of unwitnessed trauma, PBI should be included in the differential of any orbitocranial injury. In this series, we present two cases of unwitnessed pediatric orbitocranial injury that highlight the importance of gathering a detailed history, obtaining appropriate imaging studies, and using physician intuition.

Empyema necessitans as a rare manifestation of Aspergillus fumigatus infection.

Fungal empyema is an uncommon condition associated with high morbidity and mortality. Aspergillus empyema thoracis is rare and is usually associated with preexisting chronic empyema, pulmonary tuberculosis, or rupture of aspergilloma cavity. This case describes a healthy 20-year-old man presenting with chronic intractable back pain and constitutional symptoms for 6 months who was eventually diagnosed with Aspergillus empyema thoracis, complicated by empyema necessitans extending into multiple ribs and paravertebral areas. He was treated with surgical decortication, chest tube drainage, and systemic antifungal agents. The diagnostic difficulties of fungal empyema thoracis are highlighted.

An independent practice validation of the Prostate Imaging Reporting and Data System version 2 scoring system and the introduction of PDP (prostate-specific antigen density × PI-RADSv2) score to assist with further risk assessment.

Objectives: To provide concise information to clinicians on how to better interpret multiparametric magnetic resonance imaging for prostate cancer risk stratification. Materials and methods: We analyzed 2 separate cohorts. For patients receiving a Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) score of 1 or 2, we reviewed the charts of 226 patients who underwent multiparametric magnetic resonance imaging of the prostate ordered from 2015 to 2017 to determine who developed clinically significant prostate cancer (csPCa) by August 27, 2020. For patients receiving PI-RADSv2 a score of 3, 4, or 5, we reviewed the results of 733 fusion biopsies on solitary lesions. Statistical analysis was used to further determine risk factors for csPCa. Results: Ten percent of men with PI-RADSv2 a score of 1 eventually developed csPCa. Seven percent with a score of 2 were eventually diagnosed with csPCa. Only 1 of 226 with a score of 1 or 2 developed metastasis. For PI-RADSv2 scores of 3, 4, and 5, csPCa was detected in 16%, 45%, and 67% of fusion biopsies. Peripheral zone (PZ) PI-RADSv2 score of 4 or 5 and prostate-specific antigen density (PSA-D) were significant predictors of csPCa on multivariable analysis. Using a PSA-D × PI-RADSv2 score of ≤0.39, we identified 38% of men with a PI-RADSv2 score of 3 in the PZ or 3, 4, or 5 in the transition zone who could have avoided a benign biopsy. Conclusions: The vast majority of patients with PI-RADSv2 scores 1 and 2 can be safely monitored with close surveillance. Lesions with PI-RADSv2 scores of 4 and 5 in the PZ should be biopsied. Peripheral zone lesions with a PI-RADSv2 score of 3 and transition zone lesions with 3, 4, or 5 can be risk-stratified using the PSA-D × PI-RADSv2 score to determine who may safely avoid a biopsy and who should proceed to fusion biopsy.

Differentiation of pilocytic and pilomyxoid astrocytomas using dynamic susceptibility contrast perfusion and diffusion weighted imaging.

PURPOSE: Pilocytic (PA) and pilomyxoid astrocytomas (PMA) are related low-grade tumors which occur predominantly in children. PMAs have a predilection for a supratentorial location in younger children with worse outcomes. However, the two have similar imaging characteristics. Quantitative MR sequences such as dynamic susceptibility contrast (DSC) perfusion and diffusion (DWI) were assessed for significant differences between the two tumor types and locations. METHODS: A retrospective search for MRI with DSC and DWI on pathology-proven cases of PMA and PA in children was performed. Tumors were manually segmented on anatomic images registered to rCBV, K2, and ADC maps. Tumors were categorized as PA or PMA, with subclassification of supratentorial and infratentorial locations. Mean values were obtained for tumor groups and locations compared with Student's t test for significant differences with post hoc correction for multiple comparisons. ROC analysis for significant t test values was performed. Histogram evaluation was also performed. RESULTS: A total of 49 patients met inclusion criteria. This included 30 patients with infratentorial PA, 8 with supratentorial PA, 6 with supratentorial PMA, and 5 with infratentorial PMA. Mean analysis showed significantly increased rCBV for infratentorial PMA (2.39 ± 1.1) vs PA (1.39 ± 0.16, p = 0.0006). ROC analysis for infratentorial PA vs PMA yielded AUC = 0.87 (p < 0.001). Histogram analysis also demonstrated a higher ADC peak location for PMA (1.8 ± 0.2) vs PA (1.56 ± 0.28). CONCLUSION: PMA has a significantly higher rCBV than PA in the infratentorial space. DSC perfusion and diffusion MR imaging may be helpful to distinguish between the two tumor types in this location.

Advanced glycation end products and glycosaminoglycans in patients with diabetic ketoacidosis.

In some patients diabetic ketoacidosis (DKA) causes acute endothelial injury and multiorgan failure. Measurement of glycosaminoglycan (GAG) and advanced glycation end products (AGE) could provide information to help understand the biochemical events associated with poor outcomes in these patients. This study included 37 patients with DKA admitted to an intensive care unit. Blood was collected from these patients during the first day of hospitalization, 24 hours after the first sample, and 72 hours after the first sample when possible. ELISA-based assays were used to measure glucose, hemoglobin A1c, AGE, glycated albumin, and GAG levels in serum. Twenty healthy control subjects with no history of diabetes donated 1 blood sample. Control subjects had a mean age of 36.3±12.1 years; patients with DKA had a mean age of 38.1±18.5 years. Admission laboratory tests in patients with DKA included glucose 546±296 mg/dL, bicarbonate 10.1±5.5 mEq/L, anion gap 31.8±7.8 mEq/L, and creatinine 1.1±1.0 mg/dL. Patients with DKA had significantly higher level glucose and free glycated hemoglobin. Control subjects had significantly higher levels of AGE and glycated albumin. There were no differences in soluble receptor for AGE levels or GAG levels between the control subjects and patients with DKA. Patients with DKA had lower circulating levels of AGE and glycated albumin than control subjects. These results may reflect absorption of these proteins to damaged capillary surfaces or loss of proteins into interstitial spaces secondary to increased endothelial permeability.