Optic Neuritis After COVID-19 Vaccination: A Case Series and a Review of Literature.

BACKGROUND: The coronavirus disease (COVID-19) pandemic broke out in March 2020, causing tremendous damage to public health and more than 6 million deaths. After authorization for the emergency use of COVID-19 vaccines, various adverse events have been reported, including optic neuritis. COVID-19 vaccination was implemented in Taiwan in March 2021. METHODS: We report patients who developed optic neuritis after COVID-19 vaccination at one university-affiliated tertiary hospital, between March 2021 and December 2022. We also provided a literature review of optic neuritis cases after COVID-19 vaccination. RESULTS: Five patients who developed optic neuritis after COVID-19 vaccination have been identified. Four brands of vaccine used were as follows: Moderna, Pfizer-BioNTech, Medigen, and Oxford AstraZeneca. Optic neuritis developed after the first dose of vaccination in 4 patients, whereas in 1 patient, it developed after the second shot. In the 3 patients with poor initial visual acuity, intravenous methylprednisolone pulse therapy achieved substantial improvement. CONCLUSIONS: Optic neuritis is a rare but potentially vision-threatening adverse effect of COVID-19 vaccination. We suggest early diagnosis and treatment to maximize visual outcomes.

Five-year outcome of conventional and drug-eluting transcatheter arterial chemoembolization in patients with hepatocellular carcinoma.

BACKGROUND: Currently, no standard of care or therapies have been established for patients with advanced HCC. We evaluated the efficacy and safety of conventional transarterial chemoembolization using gelatin sponges or microspheres plus lipiodol-doxorubicin (cTACE) and TACE with doxorubicin-loaded drug eluting beads (DEB-TACE). METHODS: This retrospective study included 273 patients who received cTACE (n = 201) or DEB-TACE. Tumor response, survival, and adverse events were evaluated over a 5-year follow-up period. RESULTS: During 5-year follow-up, a greater percentage of patients treated with cTACE died than those treated with DEB-TACE (76.1% vs. 66.7%) (P = 0.045). At the last evaluation, all surviving patients had disease progression and no differences were seen between treatment groups. However, the time to disease progression differed between groups; median time to disease progression was 11.0 months for cTACE and 16.0 months for DEB-TACE (P = 0.019). The median survival time was 37 months in both treatment groups. No significant differences were observed between cTACE and DEB-TACE therapies in subgroups of patients with BCLC stage A or stage B + C either in survival time or time to disease progression (P values > 0.05). No significant differences were observed in survival status or disease progression between cTACE and DEB-TACE in patient subgroups with either tumor number > 5 or with the sum of the diameter of largest five HCC tumors being > 7 cm. CONCLUSIONS: DEB-TACE demonstrates greater long-term benefits than cTACE in treating treatment-naïve patients with HCC. Results of this long-term study support the use of DEB-TACE in treating HCC.

Brain contusion as the main risk factor of memory or emotional complaints in chronic complicated mild traumatic brain injury.

OBJECTIVE: To investigate the risk factors for memory or emotional complaints in patients with complicated mild traumatic brain injury (mTBI). METHODS: Retrospective analysis of medical records was conducted by physicians in a teaching hospital in Southern Taiwan, and complicated mTBI had been identified by means of computed tomography. Psychological complaints, including problems with memory and emotions, were collected by structured telephone interviews, 10-15 minutes long, and were held with subjects who agreed to participate in our study. Among 327 patients who were injured for more than two years, 190 agreed to join this study (mean age: 41.6 years; male: 60.5%; stably employed: 50.0%). We used demographic data and neurological factors to predict memory or emotional complaints without muscle power or response speed (MEMR) complaints. RESULTS: Only the presence or absence of cerebral contusions predicted memory or emotional complaints without MEMR complaints in different employed status, and the odds ratio was 4.82-13.50 times higher for those with cerebral contusions than for those without. CONCLUSIONS: Cerebral contusions were the primary risk factor for MEMR complaints in chronic complicated mTBI. Early preventive psychological intervention might be necessary for patients with complicated mTBI and cerebral contusions.

First Rib Fracture Resulting in Horner's Syndrome.

BACKGROUND: First rib fractures and traumatic Horner's syndrome are both quite rare, which can make it difficult to properly diagnose the combination of these 2 conditions in the emergency department. These conditions may be associated with severe medical emergencies, such as ongoing carotid dissection. CASE REPORT: We present the case of a 33-year-old man who sustained fractures to his right second, third, and fourth ribs and a delay in the diagnosis of left Horner's syndrome after he was involved in a traffic accident. Left Horner's syndrome was caused by a left transverse fracture of the first rib. This fracture was not detected on chest radiographs and required a 3-dimensional reconstructed neck computed tomography scan for detection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In the diagnosis of carotid artery dissection, conventional angiography is the criterion standard but is considered invasive. CTA is less invasive, time-saving, and can show more anatomic structures in the neck in addition to the carotid arteries. It is a good screening diagnostic modality in the traumatology department. Although the treatments for Horner's syndrome and first rib fracture are conservative, the early diagnosis of both conditions can resolve the anxiety and uncertainty experienced by both doctors and patients.

Diffusion-weighted imaging as an aid in the diagnosis of the etiology of medial longitudinal fasciculus syndrome.

PURPOSE: Internuclear ophthalmoplegia is caused by a lesion; stroke, multiple sclerosis, brain metastases, or trauma may produce lesions of the medial longitudinal fasciculus (MLF). Imaging techniques, such as DWI, can help identify the site of the lesion in order to speed diagnosis and lead to appropriate treatment. METHODS: Over an 8-month period, eight consecutive patients with suspected MLF syndrome (most secondary to ischemic stroke) underwent MRI examinations, including DWI sequencing, at an academic center in Taiwan. RESULTS: In all eight patients, abnormal high-signal lesions were found close to the floor of the fourth ventricle on the dorsal side of the pons. A neuroanatomical comparison showed that the location of the lesions was identical to the anatomical position of the MLF. CONCLUSION: Using DWI, good clinico-radiological correlation was found in all eight ischemic stroke patients diagnosed with MLF syndrome. DWI may broaden the application of MRI in the diagnosis of MLF syndrome.

Shielding during x-ray examination of pediatric female patients with developmental dysplasia of the hip.

Patients with developmental dysplasia of the hip (DDH) generally undergo multiple x-ray examinations of both hip joints. During these examinations, the gonads are completely exposed to radiation, unless shielded. Although many types and sizes of gonad shields exist, they often do not provide adequate protection because of size and placement issues; additionally, these shields are frequently omitted for female patients. Our aim was to assess gonad protection during x-ray examination that is provided by gonad shields designed for individual female patients with DDH.We retrospectively retrieved data from the Picture Archiving and Communication System database; pelvic plain x-ray films from 766 females, 18 years old or younger, were included in our analysis. Based on x-ray measurements of the anterior superior iliac spine, we developed a system of gonad shield design that depended on the distance between anterior superior iliac spine markers. We custom-made shields and then examined shielding rates and shielding accuracy before and after these new shields became available. Standard (general-purpose) shields were used before our custom design project was implemented. The shielding rate and shielding accuracy were, respectively, 14.5% and 8.4% before the project was implemented and 72.7% and 32.2% after it was implemented. A shield that is more anatomically correct and available in several different sizes may increase the likelihood of gonad protection during pelvic x-ray examinations.

Simple coiling of middle meningeal artery embolization for chronic subdural hematoma: An inverse probability of treatment weighting matched cohort study.

BACKGROUND: Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) has gained much attention in recent years. However, unintended embolization may occur when employing liquid embolic agents or particles. We present our clinical experience in simple coiling of MMAE to manage CSDH. METHODS: Patients underwent either surgical evacuation or MMAE with simple coiling for CSDH were reviewed. Clinical and radiographic outcomes were assessed at admission, 1-month, and 6-month intervals. Two treatment groups were matched with inverse probability of treatment weighting. RESULTS: One hundred twelve patients were included, with 27 patients in MMAE group and 87 patients in surgery group. In MMAE group, significant reductions were observed in hematoma width (admission vs. 1-month, 2.04 [1.44-2.60] cm vs. 0.62 [0.37-0.95] cm, p < 0.001). The adjusted odds ratio (aOR) of surgical rescue rate (0.77 95%CI 0.13-4.47, p = 0.77), hematoma reduction (>50%) (0.21 95%CI 0.04-1.07, p = 0.06), and midline shift improvement rate (3.22, 95%CI 0.84-12.4, p = 0.09) had no substantial disparities between two groups at 1-month follow-up. In addition, no significant difference was noted between two groups in terms of hematoma reduction (>50%) at 6-month follow-up (aOR 1.09 95%CI 0.32-3.70, p = 0.89). No procedure-related complications were found in MMA embolization group. CONCLUSION: Simple coiling for MMA had comparable outcomes with surgical evacuation for CSDH. Our findings suggest that simple coiling can be an alternative choice for liquid agents or particles in MMA embolization for CSDH with acceptable safety.

Bone marrow edema in vertebral compression fractures: detection with dual-energy CT.

PURPOSE: To assess the use of the dual-energy computed tomographic (CT) virtual noncalcium technique in the evaluation of bone marrow edema in vertebral compression fractures. MATERIALS AND METHODS: This prospective study was approved by the institutional review board; informed consent was obtained from all patients. Sixty-three consecutive patients with 112 thoracic and/or lumbar vertebral compression fractures were studied between January 2011 and April 2012. All patients underwent both dual-energy CT (100 kV and Sn140 kV, where Sn indicates the use of a 0.4-mm tin filter) and magnetic resonance (MR) imaging. Dual-energy CT data were postprocessed by using a three-material decomposition algorithm for generating noncalcium images of the collapsed bodies. Two radiologists evaluated for the presence of abnormal attenuation alterations in the bone marrow by using color-coded maps and measured CT numbers on noncalcium grayscale images. Bone sclerosis and intravertebral air were evaluated with CT scans. MR images served as the reference standard. CT numbers were subjected to receiver operating characteristic curve analysis. RESULTS: MR imaging depicted 46 edematous and 66 nonedematous vertebral compression fractures. Eighty-two bodies were classified as having less than 50% sclerosis and/or air. Significant differences in noncalcium CT numbers between edematous and nonedematous vertebral compression fractures were found for both readers (P < .0001). CT numbers for the diagnosis of bone marrow edema on the basis of MR imaging revealed areas under the receiver operating characteristic curve of 0.799 and 0.841 for readers 1 and 2, respectively (P = .56). Use of a cutoff value of -80 to differentiate edematous vertebral bodies resulted in a sensitivity of 96.3%, specificity of 98.2%, and accuracy of 97.6% in the group of vertebral bodies with less than 50% sclerosis and/or air. CONCLUSION: Dual-energy CT virtual noncalcium images were able to depict bone marrow in the collapsed vertebral bodies, especially in those with less than 50% sclerosis and/or air.

Percutaneous nephrostomy performed on kidneys with a thin renal cortex: a retrospective study of daily urine output in 46 nephrostomy procedures.

PURPOSE: This study investigated whether a thin renal cortex or any morphological kidney measurements can be predictors of post percutaneous nephrostomy (PCN) renal function, thereby lessening the need for the procedure. MATERIALS AND METHODS: All patients underwent unilateral PCN that were performed under sonographic and fluoroscopic guidance. Kidney morphological measurements were subsequently taken to measure residual renal function; a thin renal cortex was defined from a computed tomography (CT) showing a cortical thickness <10 mm. Urine output was recorded daily, with patients divided into anuric and nonanuric groups. RESULTS: Morphological measurements of residual renal function, such as renal length (p=0.004), renal width (p=0.004), renal thickness (p=0.008), and renal size (p=0.004) were significantly higher in nonanuric than anuric patients. Urine output increased by 85.47 ml/day for every millimetre increase in renal width (p=0.026) and 65.31 ml/day for every millimetre increase in renal thickness (p=0.024). Simple linear regression analyses showed that cancer patients had a significantly lower urine output (358.73 ml/day; p=0.046) than those without cancer. CONCLUSIONS: This study showed that urine output and other clinical data can provide an index to evaluate residual renal function before deciding to perform PCN procedures.

The executive functions among patients with an initial Glasgow coma scale score of 15.

Executive functions (EF) were the critical neuropsychological functions linked to long-term adaptation. Given the heterogeneous prognosis trajectories of mild traumatic brain jury (mTBI), the mildest TBI may not always be benign in the chronic stage. The present study explored the long-term EF in patients with chronic complicated mTBI and a Glasgow Coma Scale (GCS) score of 15. Fifty patients with complicated mTBI and GCS scores of 15 and 35 control participants were recruited in this study. Medical records were retrospectively analyzed, and neuropsychological assessments and subjective measures examined the neuropsychological functions. Compared with healthy controls, complicated mTBI patients with a GCS score of 15 performed significantly worse on most EF assessments, including longer reaction time (RT) and poor cognitive flexibility and abstract reasoning performances. Patients also reported more EF problems and lower quality of life (QoL) than healthy controls. Females and those with subdural hematoma (SDH) had significantly longer reaction times (RT) on executive attention tests. This study found that complicated mTBI with a GCS score of 15 had incomplete recovery of EF, even in the chronic stage. We suggest that early neuropsychological assessment and rehabilitation should be arranged for such patients.

Quantification of vessel separation using the carotid-jugular angle to predict the nerve origin of neck peripheral nerve sheath tumours: a pooled analysis of cases from the literature and a single-center cohort.

BACKGROUND: Postoperative nerve palsy is a major complication following resection of neck peripheral nerve sheath tumours (PNSTs). Accurate preoperative identification of the nerve origin (NO) can improve surgical outcomes and patient counselling. MATERIAL AND METHODS: This study was a retrospective cohort and quantitative analysis of the literature. The authors introduced a parameter, the carotid-jugular angle (CJA), to differentiate the NO. A literature review of neck PNST cases from 2010 to 2022 was conducted. The CJA was measured from eligible imaging data, and quantitative analysis was performed to evaluate the ability of the CJA to predict the NO. External validation was performed using a single-centre cohort from 2008 to 2021. RESULTS: In total, 17 patients from our single-centre cohort and 88 patients from the literature were analyzed. Among them, 53, 45, and 7 patients had sympathetic, vagus, and cervical nerve PNSTs, respectively. Vagus nerve tumours had the largest CJA, followed by sympathetic tumours, whereas cervical nerve tumours had the smallest CJA ( P <0.001). Multivariate logistic regression identified a larger CJA as a predictor of vagus NO ( P <0.001), and receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.907 (0.831-0.951) for the CJA to predict vagus NO ( P <0.001). External validation showed an AUC of 0.928 (0.727-0.988) ( P <0.001). Compared with the AUC of the previously proposed qualitative method (AUC=0.764, 0.673-0.839), that of the CJA was greater ( P =0.011). The cut-off value identified to predict vagus NO was greater than or equal to 100°. Receiver operating characteristic analysis showed an AUC of 0.909 (0.837-0.956) for the CJA to predict cervical NO ( P <0.001), with a cut-off value less than 38.5°. CONCLUSIONS: A CJA greater than or equal to 100° predicted a vagus NO and a CJA less than 100° predicted a non-vagus NO. Moreover, a CJA less than 38.5 was associated with an increased likelihood of cervical NO.

Nitroglycerine use in transcatheter arterial (chemo)embolization in patients with hepatocellular carcinoma and dual-energy CT assessment of Lipiodol retention.

OBJECTIVES: To investigate whether the addition of nitroglycerine to transcatheter arterial (chemo)embolization (TAE/TACE) can increase the delivery and effectiveness of TAE/TACE in patients with hepatocellular carcinoma (HCC) by dual-energy CT. METHODS: HCC patients (BCLC stage A or B) were randomized to (n = 51) or not to (n = 50) receive nitroglycerine and an emulsion of Lipiodol with or without doxorubicin, followed by embolization with Gelfoam pledgets. Dual-energy CT was performed pre- and 1 to 3 months post-embolization to assess changes in tumour diameter and Lipiodol levels in tumours. RESULTS: Median tumour diameter decreased from baseline in both groups with and without nitroglycerine (7.11 % vs. 12.5 %, respectively), and was statistically significant in the group receiving nitroglycerine (P = 0.023). There was no difference between the two groups in disease response (P = 0.237). The concentration and percentage of Lipiodol retained in tumours were significantly greater in patients treated with nitroglycerine compared to those without (median concentration 15.05 mg/mL vs. 4.40 mg/mL, respectively, P < 0.001; median percentage 82.01 % vs. 36.75 %, respectively, P < 0.001). CONCLUSIONS: Nitroglycerine increased delivery of the Lipiodol emulsion via TAE/TACE to HCC tumours with significant tumour reduction. Dual-energy CT can accurately quantify the amount of Lipiodol deposited in tumours. KEY POINTS: • Nitroglycerine improves delivery of tumour-targeted therapy via enhanced permeability and retention. • In hepatocellular carcinoma, nitroglycerine added to TAE/TACE showed greater tumour reduction. • Dual-energy CT can reliably quantify the amount of Lipiodol in TAE/TACE.

Diagnostic value of apparent diffusion coefficient in predicting pathological T stage in patients with thymic epithelial tumor.

PURPOSES: This study aimed to evaluate the diagnostic capacity of apparent diffusion coefficient (ADC) in predicting pathological Masaoka and T stages in patients with thymic epithelial tumors (TETs). METHODS: Medical records of 62 patients who were diagnosed with TET and underwent diffusion-weighted imaging (DWI) prior to surgery between August 2017 and July 2021 were retrospectively analyzed. ADC values were calculated from DWI images using b values of 0, 400, and 800 s/mm2. Pathological stages were determined by histological examination of surgical specimens. Cut-off points of ADC values were calculated via receiver operating characteristic (ROC) analysis. RESULTS: Patients had a mean age of 56.3 years. Mean ADC values were negatively correlated with pathological Masaoka and T stages. Higher values of the area under the ROC curve suggested that mean ADC values more accurately predicated pathological T stages than pathological Masaoka stages. The optimal cut-off points of mean ADC were 1.62, 1.31, and 1.48 × 10-3 mm2/sec for distinguishing pathological T2-T4 from pathological T1, pathological T4 from pathological T1-T3, and pathological T3-T4 from pathological T2, respectively. CONCLUSION: ADC seems to more precisely predict pathological T stages, compared to pathological Masaoka stage. The cut-off values of ADC identified may be used to preoperatively predict pathological T stages of TETs.

Recurrent inverted papilloma coexisted with skull base lymphoma: A case report.

BACKGROUND: Inverted papilloma is an uncommon neoplasm in the nasal cavity. It is a histologically benign tumor, but has a high recurrence and local invasion rate. In addition, nasal or skull base lymphoma is another rare neoplasm. The coexistence of these two tumors in one case makes the diagnosis and related treatment difficult. CASE SUMMARY: We report a case of an immunocompetent patient, who had a history of inverted papilloma 20 years ago. The patient presented with an infiltrated mass lesion in the nasal cavity with extension to the frontal base. The repeated biopsies revealed inverted papilloma without any malignant transformation. After the patient underwent a frontobasal craniotomy with total tumor excision, the final pathological examination revealed nasal inverted papilloma coexisting with diffuse large B-cell lymphoma of the skull base. CONCLUSION: Based on this case report, while managing a case of an aggressive recurrent inverted papilloma, not only squamous cell carcinoma transformation, but also other invasive malignancy, such as lymphoma, should be considered.

Comparison of the Efficacy of Two Microsphere Embolic Agents for Transcatheter Arterial Chemoembolization in Hepatocellular Carcinoma Patients.

PURPOSE: Transarterial chemoembolization (TACE) delivers cytotoxic drugs intra-arterially and induces ischemic necrosis by arterial embolization. Embolization is achieved using a variety of agents that differ widely in particle size and range, deformation, and in vivo arterial distribution. The clinical significance of these differences has not been thoroughly characterized. The present study is to compare the efficacy of Embosphere and Embozene microspheres in TACE therapy for hepatocellular carcinoma. MATERIALS AND METHODS: This retrospective study includes 108 hepatocellular carcinoma (HCC) patients who received TACE/doxorubicin with Embozene (70 patients) or Embosphere (38 patients) at a single medical center. Patient outcomes, including liver function, tumor size, tumor response, and complications after treatment, were analyzed. The change in total target lesion size and tumor response was evaluated according to embolization agent and clinical characteristics. RESULTS: The postoperative glutamate oxaloacetate transaminase (mean, 194.5 vs. 147.5; p=0.032) and bilirubin (mean, 1.11 mg/dL vs. 0.73 mg/dL; p=0.016) were higher among patients treated with Embozene, the decrease in the number (55.86±25.55% vs. 41.81±38.51%, p=0.027) and size (56.37±25.91 mm vs. 43.44±37.89 mm, p=0.001) of liver tumors relative to baseline was greater in these patients than in those treated with Embosphere. These greater antitumor effects were achieved using lower doses of doxorubicin than for treatment with Embozene. Minor complications were more common among patients treated with Embosphere than with Embozene. CONCLUSION: These results suggest that Embozene is more efficacious than Embosphere for HCC treatment using TACE/doxorubicin.