[Proton magnetic resonance spectroscopy in Asperger's syndrome: correlations with neuropsychological test scores]. / Asperger Sendromunda Proton Manyetik Rezonans Spektroskopi: Nöropsikolojik Testlerle Iliskisi.

OBJECTIVES: It has been shown that autistic spectrum patients have impaired theory of mind (ToM) performance; however, no study has investigated the relationship between ToM performance and brain neurochemistry in these patients. The present study aimed to investigate the correlations between dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC) N-acetyl-aspartate (NAA)/choline (Cho), NAA/creatine (Cr), and Cho/Cr values based on 1H magnetic resonance spectroscopy and ToM tests. METHOD: The study sample included 13 adult, right-handed, Caucasian males with Asperger's syndrome (AS) (age range: 17-37 years) and 20 controls matched by age, gender, handedness, and Wechsler Adult Intelligence Scale, Revised (WAIS-R) full-scale IQ scores. RESULTS: AS cases had significantly lower ToM performance. DLPFC NAA/Cho levels were inversely correlated to ToM scores (r = -0.738, P = 0.004). On the other hand, ToM performance improved as DLPFC Cho/Cr increased (r = 0.656, P = 0.015). ACC MRS variables were not significantly correlated with ToM performance in the AS group. No significant correlation was observed between ACC or DLPFC MRS variables and ToM performance in the control group. DISCUSSION: Because NAA/Cho was inversely correlated with ToM performance and Cho/Cr was correlated with ToM performance, it can be suggested that the Cho level was related to better ToM test performance in the AS group. An increase in the Cho peak was associated with an increase in membrane breakdown or turnover. The Cho peak was also thought to reflect cellular density and astrocytosis. It is suggested that membrane turnover and astrocytosis might affect cognitive functioning.

Metabolic changes during successful medical therapy for brain hydatid cyst: case report.

BACKGROUND: Medical therapy for hydatid disease of the brain has been reported with encouraging results especially in small or medium-sized cysts. To date, no other case correlating the metabolite levels of the cyst with albendazole treatment has been reported. CASE DESCRIPTION: A 52-year-old woman presented with left hemiparesis and seizure. Cranial magnetic resonance revealed a right frontal cystic mass lesion. A diagnosis of hydatid cyst was made, and she was put on medical therapy with albendazole. An MRS before the medical therapy was begun revealed the typical findings of a hydatid cyst with resonance of alanine, acetate, and succinate that were specific for hydatid disease, and additional nonspecific lactate peaks with an additional small peak of choline. Comparison between the multiple MRS examinations was made by comparing the metabolite ratios specific for hydatid disease to choline, which seemed stable from the beginning. Two sequential MRS imaging revealed a prominent decrease of the succinate and acetate resonance, accompanied by a smaller decline of the alanine resonance progressively, correlated with the conventional MRI findings of the cyst, which had a smaller size with blurred margins in the meantime. After 5 months of medical treatment, the cyst had completely disappeared. The patient has been monitored for 5 years and remains well without recurrence. CONCLUSIONS: This case provides additional proof that the brain hydatid cyst is a medically treatable disease in appropriate cases. Furthermore, the changes in the metabolic profile of the cyst, especially those regarding succinate and acetate may represent the efficacy of the medical treatment.

How is cognitive control of a simple mental image achieved? An fMRI study.

The aim of this study was to determine the brain regions associated with suppressing the image of an object. We used functional magnetic resonance imaging (fMRI) during five mental tasks (imagining, suppressing, erasing, free thinking and resting) performed by the subjects. The analysis showed that the suppressing, erasing and imagining conditions all activated the parietal and prefrontal regions to a different extent. These results suggest that the regions associated with cognitive control were also activated while a simple mental process was performed. Additionally, the results showed that the parietal lobe is the key region for the suppression of a mental image.

Massive Primary Intraventricular Hemorrhage Due to Idiopathic Lateral Posterior Choroidal Artery Aneurysm: Case Illustration.

Peripheral aneurysms of the lateral posterior choroidal artery are rare and mostly in association with vascular and occlusive pathologies such as moyamoya disease. To the best of our knowledge, pure lateral posterior choroidal artery aneurysms without association of any other vascular diseases are unique and only 3 cases have been reported in the literature.

Correlation of surgical outcome with neuroimaging findings in periocular lymphangiomas.

PURPOSE: To evaluate the results of surgical intervention and rate of recurrence in patients with periocular lymphangioma with respect to the anatomic extent of tumor involvement determined by neuroimaging studies. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Eighteen patients with periocular lymphangioma. METHODS: All patients underwent complete ocular examination and preoperative orbital imaging with either computed tomography or magnetic resonance imaging. Tumor location in the orbit was defined as intraconal, extraconal, or diffuse. For extraconal cases, a further classification was made as intraorbital, extraorbital, or mixed. All patients underwent orbitotomy via either a conjunctival or a skin-crease approach, depending on the tumor location. The indications for surgical intervention were varied and included preservation of visual function or cosmetic appearance in some cases and exploration of an unidentified orbital mass in others. The diagnosis of lymphangioma was established histopathologically in each case. Cases that showed recurrence at follow-up also were treated using an orbitotomy approach. MAIN OUTCOME MEASURES: Anatomic extent of tumor location in the orbit as determined by neuroimaging studies, completeness of surgical excision, pathological findings, recurrence, and visual outcome. RESULTS: Seven patients had extraconal tumors; 4, intraconal tumors, and 7, diffuse tumors. Of the patients with extraconal tumors, 4 had mixed lymphangioma and 3 had extraorbital lymphangioma. In 5 cases, the extraconal lymphangiomas were totally resected. In the remaining 13 cases with diffuse, intraconal, and infiltrating extraconal lymphangiomas, the tumors were treated with a subtotal resection procedure. At a mean follow-up of 29.4 months (range: 3-77), 2 patients with diffuse tumors developed 4 recurrences and underwent further surgical intervention for 3 recurrent events. The mean interval between treatment and recurrence was 16 months (range: 12-20). Two patients experienced decreased visual acuity due to compressive optic neuropathy in one case and operative damage in the other. CONCLUSIONS: Surgically well-delineated extraconal lymphangiomas can be resected totally with no clinical recurrence at short-term follow-up. Although intraconal, diffuse, and some extraconal lymphangiomas were treated with a subtotal resection procedure, many such cases did not demonstrate recurrence. These results are encouraging because they demonstrate that many periocular lymphangiomas can be treated successfully with good visual outcome and satisfactory cosmesis.

Cytopathologic features of pituitary carcinoma with cervical vertebral bone metastasis: a case report.

BACKGROUND: Pituitary carcinomas are extremely rare tumors of the adenohypophysis. The presence of craniospinal and/or systemic extracranial metastases is the only reliable criterion for the diagnosis of pituitary carcinoma. To date, only 2 cases have been reported correctly by fine needle aspiration biopsy (FNAB). We present an additional case of pituitary carcinoma with FNAB features. CASE: A 60-year-old woman presented with clinical features of Cushing's disease and a pituitary tumor. She underwent transsphenoidal resection of the tumor. The initial diagnosis was an adrenocorticotrophic hormone (ACTH)-producing invasive pituitary adenoma. The patient presented again with neck pain 6 years after the operation. Magnetic resonance imaging revealed metastatic tumor masses at the level of C5-C6 of the cervical vertebrae. Intraoperative fine needle aspiration and incomplete excision of metastatic tumors were performed. Cytologically, tumor cells were composed of a combination of loose groups and single cells. Neoplastic cells had a relatively monotonous appearance and displayed characteristic neuroendocrine tumor features. Immunocytochemistry from cell block sections revealed AE1/ AE3, synaptophysin chromogranin A and ACTH positivity in the tumor cells. CONCLUSION: Pituitary carcinoma with extracranial systemic metastases demonstrates typical neuroendocrine features on fine needle aspiration. In the differential diagnosis, metastatic neuroendocrine carcinomas should be kept in mind. In the absence of sufficient clinical data, these 2 entities cannot be distinguished correctly through the cytologic features.

Asymptomatic splenic artery occlusion in a child: incidental detection with Doppler ultrasonography.

Splenic arterial occlusion is a rare condition usually presenting with signs that are due to splenic infarction. To the best of our knowledge, splenic artery occlusion without splenic infarction has not been reported in the literature. The case presented here was asymptomatic, except for hypertension. The splenic artery occlusion was detected incidentally during the color Doppler examination of renal arteries that was performed to rule out stenosis as a cause. The striking Doppler finding that led to the final diagnosis was peri-pancreatic multiple tubular structures consistent with collateral flow.

Direct contrast-enhanced 3D MR venography evaluation of upper extremity deep venous system.

PURPOSE: To investigate the diagnostic value of direct contrast-enhanced three dimensional magnetic resonance (3D MR) venography in mapping the deep venous system of the upper extremities and to plan potential interventional procedures. MATERIALS AND METHODS: Nineteen cases with the diagnoses of end-stage renal disease with multiple hemodialysis catheter access were examined. Direct contrast-enhanced 3D MR venograms were obtained with 1.5 Tesla device with 3D-FSPGR pulse sequence and using body coil following the manual injection of gadolinium solution prepared by diluting 20 ml of contrast substance in 200 ml saline with a proportion of 1:10 through intravenous access opened symmetrically in antecubital fossa. In the workstation, evaluation was performed on three-dimensional images, two-dimensional multiplanar reformats and maximum-intensity projection method obtained from the source images. Intravenous DSA was performed on all the patients, and two radiologists evaluated MR venograms and conventional angiograms independently from each other. Results of MR venography and conventional angiography were then compared. RESULTS: In all cases, the MR venograms obtained were capable of supporting the diagnoses. Venous pathologies were found in 16 cases. In three cases central veins were evaluated to be patent. Results of MR venography and conventional angiography were consistent with each other (100% sensitivity and 100% specificity). CONCLUSION: Direct contrast-enhanced 3D MR venography is a well-tolerated sensitive technique in explaining the cause of the malfunctioning arterio-venous fistulas and in pre-surgical planning before placing new catheters or creating fistulas. It is possible to obtain high-quality images with this technique as an alternative to invasive angiography.

Primary intrarenal neuroblastoma in a 13-month-old girl presenting as a Wilms' tumor with pulmonary metastasis.

We report a 13-month-old girl with primary intrarenal neuroblastoma initially diagnosed as Wilms' tumor. Intrarenal neuroblastoma is exceedingly rare in pediatric age that may masquerade as Wilms' tumor clinically and radiographically and it is important to differentiate for management.

Evaluation of petrosal sinus patency with 3-dimensional contrast-enhanced magnetic resonance venography in petroclival meningiomas for surgical strategy.

BACKGROUND: The aim of this study was to perform a detailed anatomical analysis of petroclival venous structures as well as their patencies with 3D contrast-enhanced (CE) magnetic resonance venography (MRV) and to identify the potential contribution of these data to the therapeutic approach. METHODS: Ten patients (8 women and 2 men) with unilateral petroclival meningioma were examined using 3D CE MRV in addition to conventional brain protocol. Both coronal source and multiplanar reconstructed images were evaluated for the anatomical orientation. Patency of the cavernous sinus, superior petrosal sinus (SPS), and inferior petrosal sinus (IPS) was assessed. RESULTS: All the patients had a unilateral meningioma (7 on the right and 3 on the left) at the petroclival region. Both SPS and IPS were visualized with adequate intraluminal contrast enhancement in 6 patients, but IPS was absent in 3 on the lesion side, with a patent superior petrosal sinus as the drainage route. One patient had a partially occluded SPS, with IPS being the main course of cavernous sinus drainage. CONCLUSIONS: Cerebral venous anatomy is a challenge to display with noninvasive methods because of flow dynamics, and CE 3D imaging seems to be the modality of choice to evaluate the variational anatomy and patency, which is essential in petroclival meningiomas. Because the cavernous sinus drains into either IPS or SPS, the patent sinus should be protected in surgery if there is tumoral occlusion of the others.

Fluid-attenuated inversion recovery MR imaging and subarachnoid hemorrhage: not a panacea.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage (SAH) constitutes an important neurologic emergency. Some authors have suggested that fluid-attenuated inversion recovery (FLAIR) MR imaging can detect SAH that may not be apparent on CT scans but may be revealed by lumbar puncture. We sought to determine how often FLAIR MR imaging findings are positive for SAH in cases with negative CT findings and positive lumbar puncture results. METHODS: The CT scans and FLAIR MR images of all patients with suspected SAH during a 3-year interval (2000-2002) were retrospectively reviewed by a blinded reader. Among these cases, we identified 12 with CT findings that were negative for SAH, lumbar puncture results that were positive for SAH, and FLAIR MR imaging findings that were available for review. Eleven of the 12 patients had undergone FLAIR MR imaging within 2 days of CT and lumbar puncture. The 12 patients with negative CT findings were comprised of six male and six female patients with an age range of 7 to 69 years. We evaluated the true and false negative and positive FLAIR MR imaging findings for SAH by using the lumbar puncture results as the gold standard. The FLAIR MR imaging findings of 12 additional patients without SAH (as revealed by lumbar puncture) were used as control data for a blinded reading. RESULTS: For all 12 control cases without SAH, the FLAIR MR imaging findings were interpreted correctly. Of the 12 cases that had positive lumbar puncture results but false-negative CT findings for SAH, FLAIR MR imaging findings were true-positive in only two cases and were false-negative in 10. One of the two true-positive cases had the highest concentration of RBC in the series (365 k/cc), and the other had the second highest value of RBC (65 k/cc). CONCLUSION: FLAIR MR imaging cannot replace lumbar puncture to detect the presence of SAH. FLAIR MR imaging findings are infrequently positive (16.7%) when CT findings are negative for SAH. This is likely because there is a minimum concentration of RBC/cc that must be exceeded for CSF to become hyperintense on FLAIR MR images.

Aneurysmal bone cyst of the temporal bone: case report.

BACKGROUND: Aneurysmal bone cysts (ABCs) are uncommon lesions of the temporal bone and their occurrence in the calvarium is rare. CASE DESCRIPTION: A case of a right temporal ABC is reported in a 14-year-old boy who presented swelling of the right temporal region. Magnetic resonance imaging showed a destructive and expansile bone lesion on the right anterior temporal and orbital bone. The lesion was removed in total by the right temporal craniotomy and orbitozygomatic osteotomy. ABC was diagnosed in the pathologic examination. The patient had good recovery during the postoperative course. CONCLUSIONS: This report presents the diagnosis and imaging of an ABC in the temporal bone. This localization is very rare for ABC. Total excision, if feasible, is the ideal treatment.

Identification and removal of an epileptogenic lesion using Ictal-EEG, functional-neuronavigation and electrocorticography.

PURPOSE: Cases with intractable epilepsy may present with multiple lesions in their brains. Ictal-EEG carries a great value in identification of the primary epileptogenic source. On the other hand, removal of low-grade tumors located around the eloquent cortex may be risky with conventional techniques. Functional-neuronavigation (f-NN) is the integration of functional magnetic resonance imaging and stereotactic technologies; and provides interactive data regarding localization of the motor cortex. This report presents a case with dysembryoplastic neuroepithelial tumor (DNET), which was removed using f-NN and electrocorticography (ECoG) techniques. METHODS: A 19-year-old patient with intractable complex partial and secondary generalized seizures is presented. MRI revealed a low-grade tumor located in right parietal region just behind the motor cortex, and a contralateral temporal arachnoid cyst. Ictal-EEG demonstrated the right parietal origin of the seizures. The patient underwent a right parietal craniotomy and tumor excision using f-NN and ECoG techniques intraoperatively. ECoG findings correlated with epileptogenicity of the parietal lesion. RESULTS: Postoperative course was uneventful. No postoperative deficit was observed. The patient was seizure free in eight months follow-up. Pathological examination reported the lesion as DNET. CONCLUSIONS: Ictal-EEG has a very important role in identification of the epileptogenic focus in cases with multiple brain lesions. Preservation of the functional cortex is the most prominent aim during lesional surgery of epilepsy. Intraoperative mapping using f-NN and ECoG supports the orientation of the neurosurgeon to the functional and epileptogenic cortical areas; and thus, increase the safety and efficacy of surgical procedures.

Portal venous system: evaluation with contrast-enhanced 3D MR portography.

The purpose of this study is to compare contrast-enhanced three-dimensional (3D) magnetic resonance (MR) portograms to Doppler sonography in detection of portal venous abnormalities. Thirty-five consecutive patients, who were suspected of having portal venous system abnormalities, were examined with MR portography and Doppler sonography. Vascular abnormalities were identified in 27 of 35 patients. There was statistically significant agreement between the results of MR portography and Doppler sonography. The major limitation of contrast-enhanced 3D MR portography was its inability to provide objective hemodynamic data regarding flow direction and flow pattern.

Neuroarthropathy of the extremities: magnetic resonance imaging features.

The objective of this article was to review the magnetic resonance imaging (MRI) findings of four different neuroarthropathic extremities, and discuss the role of MRI in establishing a correct diagnosis. The shoulder, ankle, and knee had predominantly atrophic neuroarthropathic changes, whereas both atrophic and productive changes could be seen in the elbow. Bone marrow edema, suggesting a recent stress fracture, was detected in the elbow and knee. Osteochondral defects, or "detritic" synovitis with effusion, were extensive in all joints but exceptionally profound in the shoulder with amputation-like osteolysis and a total loss of the humeral head. Radiologists may encounter the joint manifestations of neuropathy, which may be confused with various pathologies, including tumor and septic arthritis, before the neurological diagnosis is established. MRI is helpful in detecting the extension of the disease as well as to differentiate chronic Charcot's arthropathy from septic arthritis before radiographic findings suggest the diagnosis.

Evaluation of the longus colli muscle in relation to stellate ganglion block.

BACKGROUND AND OBJECTIVES: The longus colli (LC) muscle is an important structure of the anterior cervical spine and has a critical role in stellate ganglion block. This technique involves withdrawing the needle to locate its port for injection above the anterior surface of the LC muscle; however, its exact thickness at the C5, C6, and C7 levels has not been measured. The aim of this anatomic and magnetic resonance-supported study was to evaluate the thickness of the LC muscle at these levels from the anterior tubercle of each vertebra toward the vertebral body at 5-, 10-, and 15-mm distances to provide precise anatomic data for stellate ganglion block. METHODS: Ten cadavers, 60 vertebral body specimens, and cervical magnetic resonance imaging (MRI) scans of 40 adult patients were used for measurements. RESULTS: The main findings of this study are that the thickness of the LC muscle varies between 5.0 and 10.0 mm at C6 and C7 in cadavers and between 8.0 and 10.0 mm in MRI scans. Sex has an important role; MRI scans revealed that male patients have a considerably thicker LC muscle at each vertebral level. CONCLUSION: We found a highly variable thickness of the LC muscle in anatomic and imaging studies, which may lead to negative block results.

MRI of non-neoplastic cranial complications of malignant disorders.

PURPOSE: To depict the well-known and atypical magnetic resonance imaging (MRI) findings of non-neoplastic central nervous system (CNS) complications of extra- CNS tumors and portray additional information from advanced techniques, such as diffusion and perfusion MRI. MATERIALS AND METHODS: MRI scans of 92 patients were retrospectively evaluated based on the non-neoplastic effects induced by treatment or the remote effects of the tumor itself. Patients with brain metastases and/or patients who had whole brain radiation therapy were excluded so as not to take the primary radiation effects into consideration. RESULTS: Sixteen patients (9 females and 7 males; age range, 11-68 years; median age, 45 years) had positive findings other than brain metastases. Six patients had posterior reversible encephalopathies, 3 patients had chemotherapy toxicity to the white matter, and 2 patients had acute strokes involving the posterior fossa and bilateral anterior circulation territory. Three patients had bilateral radionecrosis of the temporal lobe due to radiotherapy given for the vicinal tumor (nasopharyngeal carcinoma). One patient had encephalitis in the bitemporal region and one patient had cerebellar degeneration, each of whom had a paraneoplastic syndrome. CONCLUSION: One of the major and noteworthy complications of malignancies directly affecting survival is brain metastasis, but non-neoplastic complications are infrequently encountered and are thus underestimated, either due to the absence of a true diagnosis or the lack of information pertaining to the clinical outcome. It is important for the radiologist to recognize these effects so as to help the clinician develop an optimal treatment strategy and avoid irreversible complications.

Opposed phase imaging in lumbar disc disease: an option providing faster image acquisition times.

PURPOSE: To investigate the utility of opposed phase imaging (OPI) (in-phase and out-of-phase) in lumbar disc disease. MATERIALS AND METHODS: A total of 127 patients suspected of disc disease were examined with both traditional lumbar spine protocol (fast spin-echo [FSE] T1-weighted, T2-weighted sagittal, and T2-weighted axial) and OPI. Images were evaluated to detect the disc disease and to assess the anatomical clarity of certain spinal structures by two different radiologists using a four-point scale (1 = inadequate, 2 = adequate, 3 = good, and 4 = optimal). Results of two methods in terms of pathologic conditions and anatomical structures were compared. Comparison of the methods and the interpretations of two radiologists were performed by using kappa statistics. The difference among two methods in terms of anatomic clarity was assessed by using Wilcoxon analysis. RESULTS: Disc disease detected by each technique demonstrated concurrence (agreement was 82.4% and 93.1% for two radiologists; P < 0.05). OPI received similar scores with conventional sequences for disc disease (P > 0.05). OPI was optimal in displaying disc, marrow, osteophytes, and hemangiomas, where other structures got higher scores on conventional images (P > 0.05 and P > 0.001). But these structures had equal scores at least in one of the opposed-phase images. Acquisition time for OPI and conventional images were 4.46 and 9.01 minutes, respectively. CONCLUSION: OPI can be a faster backup technique in evaluating the lumbar disc disease. It has a shorter image acquisition time with adequate diagnostic quality. It can be a "time saver" option for busy MR centers or may be used for patients who cannot tolerate longer acquisition times.