Criteria for Determining Malignancy in Pancreatic Intraductal Papillary Mucinous Neoplasm Based on Computed Tomography.

INTRODUCTION: Determining the dignity of intraductal papillary mucinous neoplasms (IPMNs) by imaging procedures is challenging. Various CT-based criteria were evaluated. PATIENTS AND METHODS: Preoperative CT scans from 47 patients with IPMN were analyzed. Predefined criteria of malignancy were compared between patients with benign (bIPMN; n = 28) and malignant (mIPMN; n = 19) tumors, and a summation score was determined. RESULTS: Preoperative carbohydrate-antigen 19-9 levels were higher in patients with mIPMN (p = 0.013). The diameter of the main pancreatic duct was greater in patients with mIPMN (p < 0.0001). More patients with mIPMN showed bile duct obstruction (p = 0.0076), solid tumor components (p = 0.0076), contrast enhancement in cystic walls (p = 0.0086), peripancreatic lymph nodes (p = 0.0076), and abrupt diameter changes of the main pancreatic duct (p = 0.0008). The CT density of the cysts was higher in mIPMN (p = 0.0063). The diagnostic accuracy of the summation score (sensitivity: 0.84, specificity: 0.96) was greater when compared to each individual CT parameter. CONCLUSIONS: The prevalence and extent of various CT-based abnormalities are greater in patients with mIPMN, but the wide overlap limits the diagnostic value of each individual parameter. A simple summation score largely enhances the diagnostic accuracy.

A new sulcus-corrected approach for assessing cerebellar volume in spinocerebellar ataxia.

Precise volumetry of the cerebellum still remains challenging, due to thin sulci and gyri. We present a new fast and reliable sulcus-corrected approach for quantitative assessment of cerebellar atrophy, evaluated on patients with spinocerebellar ataxia (SCA). Thin-sliced T1-weighted magnetic resonance images (MPRAGE) were acquired in 11 genetically confirmed SCA6 patients and in a group of age-matched control subjects (n=14). Post-processing involves a morphological image segmentation pipeline as a basis for a sulcus-corrected cerebellar volume measurement. Cerebellar volumes and intra-rater, inter-rater and scan-rescan reproducibility were quantified. Reliability of the measurements was validated using an anatomical preparation of the cerebellum. Repeatability coefficients (RC: intra-rater/inter-rater/scan-rescan) of the method were 1.07%/1.11%/1.35%. Absolute cerebellar volumes showed good agreement with the actual volume of the anatomical preparation. The cerebellar volume of the SCA 6 was 96.3±12.1ml (mean±S.D.), which was significantly lower than the results of the corresponding control groups. The cerebellar volume correlated significantly to clinical dysfunction in SCA6. This is the first study to demonstrate the feasibility of a new sulcus-corrected approach to assess cerebellar volume. In contrast to currently used methods, this new approach may be more sensitive even to small atrophic changes affecting sulcal widening.

Developmental Venous Anomalies are More Common in Patients with Multiple Sclerosis and Clinically Isolated Syndrome : Coincidence or Relevant?

PURPOSE: Developmental venous anomalies (DVA) are congenital malformations of veins that drain brain parenchyma, with a prevalence up to 9.3% in normal populations and 29.5% in multiple sclerosis (MS) patients. Study purpose was to determine prevalence of DVAs in patients with clinically isolated syndrome (CIS) and early relapsing-remitting multiple sclerosis (RRMS) and to assess whether DVAs are related to altered clinical, magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) laboratory parameters. METHODS: Routine neurological and MRI examinations took place in a single center in 93 patients (39 CIS, 54 RRMS). Clinical disability (n = 93), MRI (n ≤ 90), CSF (n ≤ 82) parameters and DVA status were determined and compared statistically. RESULTS: A total of 29 DVAs were detected in 25 patients (25/93; 26.9%), 10 in 39 CIS patients and 15 in 54 RRMS patients. Most parameters were not significantly altered in patients with DVAs; no associated higher conversion rates from CIS to MS at 1-year (p = 0.411) or 2­year follow-up (p = 0.281) were registered. CONCLUSION: A higher prevalence of DVAs was detected in CIS and early MS patients than reported in non-MS populations, congruent to recent literature. The DVAs were not associated with significantly altered clinical outcomes, brain atrophy rates or disease progression, and no associated higher risk of CIS patients for converting to MS was found.

Hippocampal involvement in recollection but not familiarity across time: a prospective study.

For medial temporal lobe (MTL) involvement in memory formation, it is as yet unclear whether the MTL represents a single or dual (recollection/familiarity) memory system. A further controversial issue is whether or not the hippocampus is critical for the familiarity component of recognition memory. The present prospective fMRI study aimed to investigate changes of MTL involvement in recollection and familiarity at three time points following new learning: immediately after encoding, after 3 weeks and after 6 weeks. Significant hippocampal activation was observed for recollection relative to correct rejection responses at all three intervals. In addition, a decrease of signal changes in the perirhinal cortex was observed for the familiarity versus correct rejection contrasts. These findings support the idea that the MTL is a dual memory system. They also indicate a lasting hippocampal involvement in the recollection component of recognition memory and a decrease of perirhinal cortex activation associated with familiarity for time periods up to 6 weeks after new learning.

Spinal cord atrophy in spinocerebellar ataxia type 3 and 6 : impact on clinical disability.

OBJECTIVE: To quantify spinal cord atrophy and its impact on clinical disability in spinocerebellar ataxia (SCA) type 3 and 6. METHODS: Atrophy of the upper spinal cord was assessed by high resolution T1-weighted MRI of patients with SCA3 (n = 14) and SCA6 (n = 10). Furthermore, two groups of age- and sex-matched healthy control subjects (n = 24,) corresponding to the two SCA groups, were studied. Images were post-processed by a semi-automated volumetry method combining a marker based segmentation and an automatic histogram method facilitating highly reliable quantification and morphometry of the upper cervical cord in vivo. RESULTS: We found a significant reduction of normalized mean crosssectional area of the spinal cord in SCA3 (p < 0.0005), whereas in SCA6 patients normalized mean crosssectional area was in the normal range (p = 0.379). No correlation was found between spinal cord atrophy and disease duration as well as CAG repeat length in both subtypes. In SCA6 a negative dependency between clinical disability, as expressed by the International Cooperative Ataxia Rating Scale as a well established ataxia score, and the mean cross-sectional area was found (p = 0.02). A similar correlation was observed in SCA3 but did not reach statistical significance. CONCLUSION: Our results quantify for the first time in vivo spinal cord atrophy as a non-cerebellar neurodegenerative process in SCA3. Our results suggest MR volumetry of the upper cervical cord as a marker of functional importance in SCA3 and SCA6.

Reflux patterns in the ovarian and hypogastric veins in patients with varicose veins and signs of pelvic venous incompetence.

Patients with varicose veins who also had clinical and/or duplex ultrasound findings suspicious of pelvic venous incompetence (PVI) underwent selective retrograde catheter phlebography of the pelvic veins. One hundred and one patients (all female, mean age 49.3 years) underwent selective phlebography of the pelvic veins. In 68 cases (67.3%) a varicose vein recurrence after previous stripping of the greater saphenous vein was present, and about half the patients (n=45, 44.6%) were multipara ( > or =2 episodes of childbirth). The presence and extent of any reflux was documented and the ovarian and pelvic veins affected by the reflux were recorded. Retrograde selective phlebography demonstrated a PVI in 75 patients (74.2%). The left ovarian vein and the right hypogastric vein were most frequently affected by reflux (n = 41, 54.6% each). The left hypogastric vein was incompetent in 35 patients (46.6%) and the right ovarian vein in 3 cases (4%). In about half the patients with pelvic venous incompetence, reflux was demonstrated in more than one of the main pelvic veins (n=38, 50.6%). Fifty-one (68%) of the 75 patients with pelvic venous incompetence had varicose vein recurrence after previous stripping of the greater saphenous vein. Extension of the reflux into varicose veins of the groin or lower leg was demonstrated in 44 patients (58.6%). Thirty-nine patients (52%) received treatment for their pelvic venous incompetence (coil embolisation, sclerotherapy or videoscopic ovarian vein ligation). Pelvic venous reflux was present in 75% of our study population. Combined reflux in more than one pelvic vein was common and in about 60% of cases the pelvic reflux was shown to feed varicose veins of the legs. Therefore, typical clinical and/or duplex findings should lead to a strong suspicion of pelvic venous incompetence and reduce the need for selective retrograde catheter phlebography in this selected group of patients.

MRI Findings Do not Correlate with Outcome in Athletes with Chronic Groin Pain.

This trial aimed to assess the value of MRI in the differential diagnosis of chronic groin pain in athletes, a condition caused by various pathologies, the most common being posterior abdominal wall deficiency, osteitis pubis and muscular imbalance. Nineteen subjects with clinically ruled-out hernia and recurrent episodes of exercise-triggered groin pain were assessed. Dynamic MRI was performed under Valsalva manoeuver and at rest within a training- free period and after training activity. Follow-up was performed after 4 years using a questionnaire and physical examination. An incipient hernia was seen in one case, Valsalva manoeuver provoked a visible bulging in 7 others (3 bilateral). Eight athletes showed symphysitis (accompanied by bulging in 3 cases). MRI visualized one hydrocele, one osteoma of the left femur, one enchondroma of the pubic bone, and one dilated left ureter without clinical symptoms or therapeutic relevance. MRI findings after training and during the training free period did not vary. Fifteen participants were available for a follow-up control examination 4 years later - one suffered from ongoing pain, eleven were free of symptoms and three had improvement. However, most of them improved only with changing or reducing training. There were four participants with a specific therapy of their MRI findings. MRI revealed a variety of pathological findings in athletes suffering from chronic groin pain, but it was not reliable enough in differentiating between diagnoses requiring conservative or operative treatment. The MRI examination within the training interval did not have an advantage to that within the training-free period. Further randomized prospective trials with a long follow-up should establish whether MRI findings could be of help in the choice between conservative and surgical treatment for chronic groin pain. Key pointsMRI findings after training and during the train free period did not vary.MRI revealed a variety of pathological findings in athletes suffering from chronic groin pain, but it was not reliable enough in differentiating between diagnoses requiring conservative or operative treatment.

Central Atrophy Early in Multiple Sclerosis: Third Ventricle Volumetry versus Planimetry.

BACKGROUND AND PURPOSE: Cerebral atrophy has been suggested to be a reliable magnetic resonance imaging (MRI) predictor of subsequent disability in all stages of multiple sclerosis (MS). However, no accepted methodology for routine clinical use exists to date. We sought an easy to apply and fast technique to evaluate cerebral ventricular volume in patients with MS with similar accuracy as a semiautomatic volumetric method. METHODS: The study included 104 patients, 61 diagnosed with MS and 43 with clinically isolated syndrome. In addition, 30 healthy controls were enrolled. Physical disability was assessed with the expanded disability status scale and cognitive disability with the Multiple Sclerosis Inventory Cognition (MUSIC) test. All subjects received standardized 3-dimensional (3D) MR-imaging on a 3 T scanner. Third ventricle volume (3VV) was obtained from 3D T1-weighted images using a semiautomated technique, and compared against planimetric assessment of the width of the third ventricle aligned (a3VW) and unaligned (u3VW) to anatomical landmarks. RESULTS: a3VW was obtained within seconds with excellent intra- and interrater agreement, and outperformed volumetric measurements regarding the differentiation of MS patients from healthy controls. a3VW had the strongest correlations with 3VV (r = .78, P < .001) and showed moderate inverse correlation with MUSIC cognition score (r = -.310, P < .005). CONCLUSIONS: a3VW is a time-effective and robust biomarker that has strong correlations with volumetric measurements and can be established as standard in the MRI quantification of central brain atrophy in patients with early MS.

Relevance of early cervical cord volume loss in the disease evolution of clinically isolated syndrome and early multiple sclerosis: a 2-year follow-up study.

Upper cervical cord area (UCCA) atrophy is a prognostic marker for clinical progression in longstanding multiple sclerosis (MS). The objectives of the study were to quantify UCCA atrophy and evaluate its impact in clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS); to compare converting CIS patients with stable CIS, and to study changes of UCCA and brain white matter (WM) and grey matter (GM) at 2-year follow-up. 110 therapy-naive patients including 53 CIS [6 ± 6 months after symptom onset (SO)] and 57 early RRMS (SO: 12 ± 9 months) underwent sagittal 3D-T1w brain MR (3T). Mean UCCA (C1-C3 level), WM and GM, disability status (EDSS), pyramidal and sensory functional scores, motoric fatigue were assessed at baseline (BL), 12 and 24 months. Volumes were compared with 34 age- and gender-matched healthy controls to assess atrophy. RRMS (78.1 ± 8.7 mm2, p = 0.011) and converting CIS (77.3 ± 8.0 mm2, p = 0.046) presented with baseline UCCA atrophy, when compared with controls (82.7 ± 5.2 mm2), but not stable CIS (82.6 ± 7.4 mm2, p = 0.998). Baseline WM was reduced in RRMS (509.3 ± 25.7 ml vs. CONTROLS: 528.4 ± 24.1 ml, p = 0.032). Baseline UCCA correlated negative with muscular weakness and fatigability in all patients and RRMS. EDSS exceeding 3 was associated with lower baseline UCCA. Longitudinal atrophy rates were higher in UCCA than in brain volumes. Early cervical cord atrophy in CIS and RRMS was confirmed and may represent a potential new risk marker for conversion from CIS to MS. Baseline atrophy and atrophy change rates were higher in UCCA compared to WM and GM, suggesting that cervical cord volumetry might become an additional MRI marker relevant in future clinical studies in CIS and early MS.

Gray matter alteration associated with pain catastrophizing in patients 6 months after lumbar disk surgery: a voxel-based morphometry study.

INTRODUCTION: Pain catastrophizing (PC), the increased attention to harmful aspects of pain (magnification), and the belief of low controllability (helplessness) has been shown to be important in the maintenance of pain. A growing research on structural alterations in chronic pain revealed an association between PC and brain areas that are involved in affective and cognitive pain processing. However, little is known about a differential effect of the components magnification and helplessness. OBJECTIVE: The aim of this study was to identify brain regions associated with overall PC and with the single components of magnification and helplessness. METHODS: We investigated 29 patients 6 months after lumbar disk surgery using voxel-based morphometry. Magnification and helplessness were assessed with subscales of the Avoidance-Endurance Questionnaire (AEQ); overall PC was computed using the sum score. The structural brain imaging data were preprocessed and analyzed using SPM8 and VBM8. Multiple regression analyses were performed with PC scales as predictors and depression as covariate. RESULTS: Pain catastrophizing was significantly associated with cortical gray matter in brain areas involved in processing attentional, sensory, and affective aspects of pain, including the left posterior cingulate cortex, supplementary motor area, and medial frontal gyrus. In addition, we provide preliminary evidence for brain structure association related to magnification and helplessness. CONCLUSION: This study provides evidence for PC-related structural alterations in patients with low back pain, which are consistent with findings from previous research in different chronic pain disorders. This study is the first to evaluate brain changes related to differential domains of PC.

Dissociation of grey and white matter reduction in spinocerebellar ataxia type 3 and 6: a voxel-based morphometry study.

The aim of this study was to examine the different patterns of cerebellar and/or brainstem atrophy in spinocerebellar ataxia (SCA) type 3 and 6. Eighteen patients (SCA3 n=9, SCA6 n=9) and 15 healthy volunteers were studied. Voxel-based morphometry (VBM) was applied to segmented grey matter (GM) and white matter (WM) of high-resolution T1-weighted brain volumes of each group. We found reduction of grey matter in the pons as well as in the vermis in SCA3 as compared to control subjects. In SCA6 significant grey matter loss was found in hemispheric lobules bilaterally as well as in the vermis. White matter analysis revealed significant changes in SCA3, especially in the pons, in the white matter surrounding the dentate nucleus (DN) and in the cerebellar peduncles, whereas no significant white matter reduction was found in SCA6 patients. Our results demonstrate different patterns of grey and white matter affection detected by magnetic resonance imaging (MRI) in SCA3 and SCA6 patients, confirming the pathological concept of cortical cerebellar atrophy in SCA6. In contrast, SCA3 represents a form of ponto-cerebellar atrophy with predominant affection of pontine nuclei and fibre tracts.

Standard-protocol moving-table magnetic resonance angiography for planning of interventional procedures in patients with peripheral vascular occlusive disease.

PURPOSE: This study aimed to evaluate the usefulness of magnetic resonance angiography (MRA) for the planning of interventional procedures in the lower extremity vascular territory. MATERIALS AND METHODS: Patients with peripheral vascular occlusive disease (PVOD) underwent MRA for planning of percutaneous interventional treatment. Digital subtraction angiography was performed in patients scheduled for interventional treatment and served as the standard of reference. RESULTS: In 148 out of 150 cases (98.7%), the necessity for an intervention was recognized correctly; 137 out of 150 interventions (91.3%) were correctly planned based on MRA results. CONCLUSION: Contrast-enhanced MRA of the lower extremities is a safe, noninvasive tool for preinterventional assessment of patients with PVOD. It allows exact planning of endovascular interventions.

Apomorphine reduces BOLD signal in fMRI during voluntary movement in Parkinsonian patients.

Our group investigated modulatory effects of apomorphine on cerebral activation patterns during finger tapping movements in seven Parkinson's disease (PD) patients off medication. Cerebral activation was measured according to an established fMRI protocol. Apomorphine application disclosed a reduction of cerebral activation patterns to the contralateral precentral gyrus affecting both clinically affected and unaffected sides; tapping with the unaffected hand additionally revealed activation in the contralateral postcentral gyrus. These findings contradict those of similar functional imaging studies performed in PD to date, which variously found augmentation of cerebral activation patterns in Parkinsonian patients after dopaminergic stimulation. One conceivable explanation for our singular results would be preferred binding of apomorphine to presynaptic dopaminergic receptors, leading to inhibition of endogenous dopamine release and resultant diminished dopaminergic stimulation, reflected in diminished cerebral activation patterns. These findings warrant future consideration and further investigation of possible central inhibitory effects of dopaminergic therapy in functional imaging studies in PD.

Imaging osteomyelitis with Tc-99m-labeled antigranulocyte antibody Fab' fragments.

PURPOSE The purpose of this study was to evaluate the diagnostic value of Tc-99m-labeled antigranulocyte antibody fragments in the diagnosis of osteomyelitis. MATERIALS AND METHODS Thirty immunoscintigrams were evaluated retrospectively with 740 MBq (20 mCi) Tc-99m-labeled antigranulocyte antibodies. The final diagnoses were confirmed by histology, magnetic resonance imaging, computed tomography, and clinical follow-up. RESULTS In the retrospective analysis, 20 of 30 patients (67%) demonstrated a true-positive result. Three of 30 patients (10%) had a false-positive result. A false-negative result was found in a diabetic patient with a perforating ulcer of the foot. Six of 30 patients had a true-negative result. A high sensitivity of 95%, a relatively high specificity of 67%, and a high diagnostic accuracy of 86% were present in this study. CONCLUSION Tc-99m labeled monoclonal antibody-Fab' fragments are suitable for the detection of osteomyelitis. Its clinical application is simple. Its use guarantees a reliable and accurate diagnostic result just 1 to 2 hours after injection, making a late scan unnecessary. Coxarthrosis or hyperostosis can lead to false-positive results. A perforating ulcer of the foot may result in a false-negative conclusion.

A bilateral occipitotemporal network mediates face perception.

The aim of the present study was to further explore the neuronal mechanisms of face processing in healthy subjects which may help to understand the difficulties experienced by prosopagnosia subjects. A further goal was to compare face specific activation patterns in the right and left occipital face area (OFA) and fusiform face area (FFA) for famous faces, non-famous faces and caricatures of famous faces in four individuals suffering from developmental prosopagnosia (DP) and seven healthy controls, using functional magnetic resonance imaging and psychophysiological interaction analysis (PPI). Control subjects showed higher face related activations in the right compared to the left FFA. Caricatures of faces of famous people and photographs of non-famous faces yielded higher percent signal changes in the OFA and FFA compared to photographs of famous faces. These data support the idea that the OFA and FFA discriminate between familiar and new face representations. The activation patterns of DP subjects were heterogeneous, with none of the patients showing bilateral face related activations in both OFA and FFA. There was no evidence of a left hemispheric activation when the right homologue failed to be activated, supporting the view of a right hemispheric dominance in face perception. PPI analysis indicated a link between activation of the right FFA and the other three tested regions, the left FFA and the right and left OFA. In summary, all four face related brain regions appear to be necessary for successful face processing, and disruption of one component may lead to face recognition deficits.

Benefit of repetitive intrathecal triamcinolone acetonide therapy in predominantly spinal multiple sclerosis: prediction by upper spinal cord atrophy.

Intrathecal injection of triamcinolone acetonide (TCA) has been shown to provide substantial benefit in a subset of progressive multiple sclerosis (MS) patients with predominant spinal symptoms. We examined whether atrophy of the upper spinal cord (USC) as measured by MRI can serve as a predictive marker for response to repetitive intrathecal TCA application. Repetitive administration of 40 mg TCA was performed in 31 chronic progressive MS patients up to six times within 3 weeks. Expanded Disability Status Scale (EDSS) and maximum walking distance (WD) were assessed before and after the treatment cycle. Cervical 3D T1-weighted images were acquired on a 1.5T scanner at baseline. Mean cross-sectional area of the USC was determined using a semi-automated volumetry method. Results were compared with a group of 29 healthy controls to group patients into those with and without atrophy. Results show a negative correlation between the degree of USC atrophy and treatment benefit. A higher treatment benefit in patients with little USC atrophy but short initial maximum WD was observed. Absence of USC atrophy as measured on MRI is a predictive marker for intrathecal TCA therapy outcome in progressive MS. Patients with initial poor walking abilities, but only little or no atrophy, benefited most from TCA therapy.

Mediastinal pancreatic pseudocyst with isolated thoracic symptoms: a case report.

INTRODUCTION: Mediastinal pancreatic pseudocysts represent a rare complication of acute or chronic pancreatitis. CASE PRESENTATION: A 55-year-old man with a history of chronic pancreatitis was admitted with intermittent dyspnea, dysphagia and weight loss. Chest X-ray, computed tomography and magnetic resonance imaging revealed a large paracardial pancreatic pseudocyst causing cardiac and esophageal compression. CONCLUSION: Mediastinal pancreatic pseudocysts are a rare complication of chronic pancreatitis. These pseudocysts may lead to isolated thoracic symptoms. For accurate diagnostic and therapy planning, a multimodal imaging approach is necessary.

Domain-specific retrieval of source information in the medial temporal lobe.

Memory for context information (source memory) has been reported to rely on structures in the medial temporal lobe (MTL). Perirhinal cortex (anterior MTL) and parahippocampal cortex (posterior MTL) have distinct connectivity patterns with sensory neocortex, suggesting a possible modality-dependent organization of memory processes. The present study investigated the neural substrates of two different types of source information of newly encoded material using functional magnetic resonance imaging: auditory (speaker voice) and visual (texture and colour). Source judgements during retrieval were reliably above chance level for both modalities and performance did not differ between the auditory and visual condition. During encoding, activity predictive of subsequent source recollection was observed in the anterior hippocampus/parahippocampal gyrus, irrespective of source modality. During retrieval, on the other hand, a regional dissociation emerged: bilateral parahippocampal cortex discriminated between correct and incorrect auditory but not visual source judgements, whereas left perirhinal/entorhinal cortex showed the reverse pattern. These findings are consistent with recent lesion evidence of disrupted auditory but intact visual source memory following damage to the parahippocampal cortex. Results are discussed with respect to anatomical models of corticoparahippocampal connectivity and the functional organization of the MTL.

Cross-modal processing in auditory and visual working memory.

This study aimed to further explore processing of auditory and visual stimuli in working memory. Smith and Jonides (1997) [Smith, E.E., Jonides, J., 1997. Working memory: A view from neuroimaging. Cogn. Psychol. 33, 5-42] described a modified working memory model in which visual input is automatically transformed into a phonological code. To study this process, auditory and the corresponding visual stimuli were presented in a variant of the 2-back task which involved changes from the auditory to the visual modality and vice versa. Brain activation patterns underlying visual and auditory processing as well as transformation mechanisms were analyzed. Results yielded a significant activation in the left primary auditory cortex associated with transformation of visual into auditory information which reflects the matching and recoding of a stored item and its modality. This finding yields empirical evidence for a transformation of visual input into a phonological code, with the auditory cortex as the neural correlate of the recoding process in working memory.