Lateral cephalometric analysis in Thai patients without clinical features of obstructive sleep apnea syndrome.

Objective: To obtain referent normative values of lateral cephalometric parameters of the upper airway in Thai people without clinical features of obstructive sleep apnea syndrome (OSAS). Methods: A total of 105 healthy subjects (80 males and 25 females) were recruited. Inclusion criteria were healthy people age > 18 years with body mass index (BMI) of < 30 kg/m2, normal visual harmony of facial profile, no history of snoring or witnessed apnea, and no excessive daytime sleepiness (Epworth Sleepiness Scale ≤ 8). All subjects must have a regular sleep pattern with total sleep duration of 7-9 hours and must have no complaint of difficulty sleeping. Exclusion criteria were pregnant women, patients with previous orthodontic treatment, corrective jaw surgery, upper airway surgery, neoplasm, irradiation in head and neck, and patients who had underlying illnesses using medication or substance which affected the sleep-wake cycle. All subjects had lateral cephalometric radiographs taken with a standardized technique. Every data was measured twice on separate occasions. Results: The reliability of repeated measurements was excellent shown by intraclass correlation coefficients ranging from 0.95 to 0.99. The baseline data were presented in mean ± SD. SNA, SNB, PAS, MPH and PNS-P in males were 84.3 ± 4.0, 81.5 ± 4.1, 14.2 ± 3.4, 16.1 ± 5.3, and 34.8 ± 6.1, respectively. SNA, SNB, PAS, MPH and PNS-P in females were 84.4 ± 3.1, 80.7 ± 3.2, 11.1 ± 3.3, 10.8 ± 4.9, and 32.3 ± 3.1, respectively. The parameters that were different between both genders included N-ANS, GN-GO, H-PP, MPH, PAS, and TL. (p < 0.05) Conclusion: To date, this study has possibly represented the largest local database of lateral cephalometric measurements focusing on Thai people without clinical features of OSAS. It may be another useful reference for future research and clinical practice.

Striatal hyperdensity in hemichorea patient: Case reports and review literatures.

Objective: To report three cases of a unique clinicoradiological manifestration of chorea associated with non-ketotic hyperglycemia. Methods: A retrospective review of clinical, radiological and laboratory findings in three patients with chorea associated with non-ketotic hyperglycemia and a review of relevant literature were done. Results: Three patients presented with acute hemichorea, two patients with a history of long standing diabetes mellitus and one without. The initial cranial CT scans revealed hyperattenuation at the basal ganglia contra-lateral to the side of chorea in two cases and bilateral involvement in one case. The laboratory findings showed a non-ketotic hyperglycemic state in all patients and, hence, hyperglycemia-induced chorea was diagnosed. Chorea in all patients responded well to treatment for hyperglycemia. Conclusion: Acute chorea associated with diabetic non-ketotic hyperglycemia may present with acute neurologic symptoms mimicking stroke. Recognition of this unique clinicoradiological appearance is important because correction of the underlying hyperglycemia will lead to rapid improvement of chorea.

Computed tomographic findings in non-traumatic hemorrhagic stroke.

OBJECTIVE: To analyze CT findings in hemorrhagic stroke patients correlation with clinical outcome and assess the interobserver agreement of hemorrhagic stroke identification on CT imaging. MATERIAL AND METHOD: CT imaging features of 131 cases and clinical data were verified and collected at Siriraj Hospital from Jan 2004 to Dec 2005 and retrospectively analyzed for type, location, mass effect, size of hemorrhage, intraventricular extension, initial level of consciousness (GCS), hospital length of stay and patient outcome. The percentages, predictive values, kappa were calculated. RESULTS: From all types of hemorrhagic stroke, intracerebral hemorrhage remains a common and devastating clinical problem. The most common site was the thalamus and basal ganglia. In the present study, the authors found that fifty-three cases (53/131 cases, 40.5%) with thalamic-ganglionic hemorrhage, nineteen cases (19/131 cases, 14.5%) in lobar hemorrhage, five cases (5/131 cases, 3.8%) in cerebellum, five cases (5/131 7 cases, 3.8%) in brainstem and eight cases (8/131 cases, 6.1%) occurred in multiple locations. There were twenty-five cases (25/131 cases, 19.1%) of subarachnoid hemorrhage, thirteen cases (13/131 cases, 9.9%) of subdural hemorrhage and three cases (3/131 cases, 2.3%) of intraventricular hemorrhage. Two variables on CT imaging, identified as significant as early mortality predictors, were hematoma volume more than 60 cm3, and presence of intraventricular hemorrhage extension (p < 0.05). The mass effect defined as midline and/or enlargement of contralateral ventricle was not significant (p = 0.067). The present study found concordance between CT brain interpretation by two neuroradiologists for the type of hemorrhagic stroke was very good, Kappa = 0.861 as well as for location was 0.866. CONCLUSION: CT imaging is an imaging instrument for early identification of hemorrhagic stroke patients and providing imaging evidence of high mortality risk.

Diagnostic accuracy of MR imaging in tuberculous spondylitis.

OBJECTIVE: To systemically evaluate MR imaging features of tuberculous spondylitis and to find features that may help differentiating tuberculosis from other spinal diseases. MATERIAL AND METHOD: Retrospective review of 65 MR imaging of two groups of patients between January 2002 and December 2005. Thirty-one patients were diagnosed as tuberculosis spondylitis and the rest were a randomly selected group of 34 patients with other spinal diseases. All images were reviewed by two neuroradiologists blinded to clinical data. Sensitivity and specificity of each MR imaging features were calculated. RESULTS: Three most useful MR imaging features with high sensitivity and specificity (> 80%) were endplate disruption (100%, 81.4%), paravertebral soft tissue (96.8%, 85.3%), and high signal intensity of intervertebral disc on T2W (80.6%, 82.4%). High sensitivity but low specificity signs in MRI included bone marrow edema (90.3%, 76.5%), bone marrow enhancement (100%, 42.5%), posterior element involvement (93.5%, 76.5%), canal stenosis (87.1%, 26.5%), and spinal cord or nerve root compression (80.6%, 38.2%). Low sensitivity but high specificity features in MRI were intervertebral disc enhancement (63.3%, 84.2%), vertebral collapse (58.1%, 85.3%), and kyphosis deformity (67.7%, 82.4%). Overall, the sensitivity and specificity of MRI for spinal tuberculosis were 100% and 88.2% respectively. CONCLUSION: The authors presented three good to excellent sensitivity and specificity MR imaging features for spinal tuberculosis, end plate disruption, paravertebral soft tissue formation, and high signal of intervertebral disc on T2W. In contrast to a previous study, most of the presented cases still presented with classic radiological pictures of "two vertebral disease with the destruction of the intervertebral disc". Only a small portion of the patients revealed sparing intervening disc or isolated single vertebral body involvement, which possibly reflected the early stages of the disease process.

Cranial dural arteriovenous fistula: Predisposing factors to aggressive symptoms.

Objective: To evaluate the clinical and angiographic data of cranial dural arteriovenous fistula in Thai patients and to determine the predisposing factors to aggressive symptoms. Methods: Retrospective review of 71 patients with cranial dural arteriovenous fistula who underwent cerebral angiography at Siriraj Hospital between July 2002 – February 2006. Their clinical manifestations were classified as benign or aggressive symptoms. The relationship between aggressive symptoms and the following factors were studied: gender, location of the fistula, classification according to venous drainage pattern, presence of cerebral sinus thrombosis, and shunt multiplicity. Linear-by-linear association and chi-square test were used to determine statistical significance. Results: Sixteen (22.5%) of 71 patients with cranial dural arteriovenous fistula had aggressive presenting symptoms. Factors that significantly correlate with aggressive symptoms were location of the fistula, retrograde leptomeningeal venous drainage, presence of cerebral sinus thrombosis, and multiplicity. Factor which was not significantly correlated with aggressive symptoms was gender. Conclusion: This study evaluated clinical data and angiographic features of cranial dural arteriovenous fistula in Thai patients. Predisposing factors to aggressive symptoms were location of the fistula, retrograde leptomeningeal venous drainage, presence of cerebral sinus thrombosis, and multiplicity.

Imaging findings of CNS lymphoma in Siriraj Hospital.

Objective: To describe the CT and MR features of CNS lymphoma (both PCNSL and SLCNS groups) and to determine whether there is a difference. Methods: A retrospective study of CNS lymphoma in 100 patients at the department of Medicine, Siriraj Hospital, Mahidol University, during January 1997 – September 2002, for neuroimaging analysis. We retrospectively analyzed all available CT and MR findings of these patients by a neuroradiologist who was blinded to the patients’ clinical histories. The imaging studies were evaluated for density in CT, intensity in MR, pattern of enhancement, leptomeningeal enhancement, number of lesions, location and degree of edema. For MRI of spines, we additionally classified 4 menifestations: osseous lymphoma, spinal epidural lymphoma, lymphomatous meningitis and intramedullary lymphoma. Results: Only 33 CTs of the brain, 12 MRs of the brain and 11 MRs of spines were available for retrospective evaluation in this study. For CTs of the brain, most of the lesions showed hyperdensity on non-contrast CT (45% in PCNSL and 59% in SLCNS) with homogenous enhancement on contrast CT (78% in PCNSL and 75% in SLCNS). Eleven percent of ring enhancement lesions in PCNSL and eight percent in SLCNS were found in all patients with HIV infection. For MRs of the brain, most lesions of PCNSL and SLCNS showed hypo-isointensity in both T1W and T2W and homogenous enhancement. Locations of PCNSL were found in cerebral white matter and corpus callosum (55.5%) and basal ganglia (33.3%). SLCNS were found in cerebral white matter (50%), cavernous sinus (37.5%), basal ganglia (6.25%) and brainstems (6.25%). Conclusion: CNS lymphoma has been increased in Thailand. Imaging findings in PCNSL and SLCNS groups were not difference in this study. The pattern of imaging findings of CNS lymphoma in Thailand was similar to CNS lymphoma in the world.

Combined surgery and endovascular treatment of complicated traumatic carotid-cavernous fistulas: Results and illustrated cases.

Objective: To review Siriraj Hospital’s experiences with direct surgical treatment of complicated traumatic carotid-cavernous fistulas (CCFs) in the context of multidisciplinary approach. Methods: This study is a retrospective review of complicated direct carotid cavernous fistulas (CCFs) that had opened surgery after failure of detachable balloon embolization. Data were collected from medical records, radio-angiographic records, and follow-up results of combinations of treatment. Results: From 1993- April 2003, we have total 25 cases of combined surgery and endovascular treatment of traumatic carotid-cavernous fistulas (CCFs). Causes of unsuccessful balloon embolization are small-hole fistula, deflation of the balloon, difficult position of fistula, false aneurysm, risk of intracavernous internal carotid artery (ICA) occlusion, and tortuosity of ICA and draining veins. Various procedures were performed and all patients have good results with completed resolution of clinical triad symptoms. On follow-up cerebral angiography of 16 patients that received cavernous sinus packing, we could preserve the patency of ICA in 8 patients but 5 patients had thrombosis of ICA without ischemic events. In 3 patients, an operation to occlude the ICA was performed after failure of cavernus sinus packing. Conclusions: The standard treatment of carotid cavernous fistula is endovascular balloon embolization. When the endovascular treatment fails, surgical packing of cavernous sinus is immediately considered an alternative way to cure the CCFs and to offer additional technique to help increase the patency of ICA.

The limited protocol MRI in diagnosis of lumbar disc herniation.

OBJECTIVE: To assess agreement in detection of lumbar disc herniation (LDH) between limited and full protocol MRI. MATERIAL AND METHOD: 123 patients who requested lumbar MRI for diagnosis of disc herniation were assessed The full protocol MRI composed of sagittal T1-wi, sagittal T2-wi and axial T2-wi was performed on each patient. The sagittal T2-wi was selected as the limited protocol MRI. The limited and full protocols MRI of each patient were separately interpreted by three neuroradiologists to assess disc herniation and nerve root compression. The consensus results of limited and full protocol were compared. The diagnostic performance of each protocol was analyzed using surgery as the gold standard. RESULTS: There were 62 females and 61 males enrolled into the study between the age of 21-60 years old (means = 42.91 years). The duration of pain was 1-204 months (mean = 31.20 months). The degree of severity was mild in 23.58%, moderate 45.52% and severe 30.89% of cases. Thirty-three cases were operated on. For detection of LDH, the limited protocol gave the same interpretation results as the full protocol (0 = 1.04, 95%CI = 0.94, 1.14 with accepted range of 0.95-1.05). In nerve root compression, the limited protocol was not accurate as the full protocol (0 = 0.75, 95%CI = 0.87, 0.63). The sensitivity, specificity, accuracy, PPV, NPV, and LR+ in the surgical group of limited protocol in diagnosis of LDH were 82.61%, 80%, 81.82%, 90.48%, 60.67%, 4.13 and in nerve root compression were 54.84%, 100%, 57.58%, 100%, 12.5% respectively. The same statistics of full protocol MRI in diagnosis of LDH were 82.61%, 70.80%, 78.79%, 86.36%, 63.64%, 2.75 and of nerve root compression were 80.65%, 100%, 81.82%, 100%, 25% respectively. The sensitivity and specificity in diagnosis of LDH were not different in both protocols but the sensitivity of nerve root compression was statistically significant different (p < 0.013, 95%CI = -0.33, -0.25). CONCLUSION: The authors concluded that limited protocol MRI may replace full protocol MRI in diagnosis of LDH but not in nerve root compression.

Pediatric sinusitis:symptom profiles with associated atopic conditions.

INTRODUCTION: Sinusitis is a very common disease in childhood. Clinical manifestations in childhood sinusitis are different than in adult. Information in childhood sinusitis in Thailand is limited. We performed a prospective descriptive study to determine clinical characteristics of childhood sinusitis in Thailand MATERIAL AND METHOD: One hundred pediatric patients with clinical diagnosis of sinusitis attending pediatric allergy clinic, pediatric outpatient clinic, and pediatric ENT clinic were recruited. Clinical diagnosis was defined by presence of symptoms indicating upper respiratory infections with exudates at middle meatus by anterior rhinoscopy. Thorough history taking and physical examinations were conducted with findings recording into sinusitis questionnaire. Sinus radiographs were taken in 77 patients and were read blindly a single radiologist who was unaware of clinical conditions of patients. Allergy skin prick tests were performed with a panel of common aeroallergens in Thailand. RESULTS: Age range of the 100 patients were between 1.7 to 12.4 years with a mean (+/- SD) of 6 +/- 2.72 years. History of atopic disease among patients and their families was positive in 49% and 47% respectively. Four most common clinical manifestations were rhinorrhea (95%), nocturnal and productive cough (91%), nasal congestion (74%) and posterior nasal dripping (66%). The three most common signs were obstruction of middle meatus (100%), swelling of turbinates (92%) and granular pharynx (48%). All paranasal sinuses X-rays were abnormal with maxillary sinus being the most commonly involved sinus (99%) followed by ethmoid sinus (91%). The majority of patients had involvement of more than one sinus. Skin prick tests were positive in 53.6%. The two most common sensitizing allergens were dust mites (57.7) and cockroaches (18.6%). CONCLUSION: The presence of symptoms of rhinorrhea, cough, nasal congestion and posterior nasal drip should alert physicians for diagnosis of sinusitis in pediatric patients. Maxillary and ethmoid sinus were the most common sinuses involved. Atopic predisposition is present in up to 53.6% in this population.

The alien hand syndrome: report of a case and review of the literature.

The term "alien hand syndrome (AHS)" comprises many clinical signs of which the common features are the involuntary motor movement of the affected limb and the denial of limb ownership. It can result from several diseases involving corpus callosum or medial frontal cortex. Two major types of AHS were previously classified, callosal and frontal types. Moreover posterior subtype of which the lesions do not involve corpus callosum have been reported. In the present report, the authors describe a 57-year-old man with AHS, aggressive behavior and hemispatial neglect which are the rare manifestations of callosal damage. Neuroimaging demonstrated subacute infarction of entire corpus callosum from the rostrum to splenium. A review of the literature on these abnormalities is included in the present paper.

SPECT as an aid for clinicians in the diagnosis of alzheimer's disease: A case report and review of current diagnostic approaches and the need forearly accurate diagnosis to optimize treatment.

A case of 66 year-old male with Alzheimer's dementia with classical 99mTc-ECD SPECT imaging findings is reported. The history, physical examination, and investigation, are described. Biological markers which are new used for the diagnosis of Alzheimer's dementia and current treatment are discussed.