Qualitative and quantitative evaluation for the heterogeneity of cortical tubers using structural imaging and diffusion-weighted imaging to predict the epileptogenicity in tuberous sclerosis complex patients.

PURPOSE: We aimed to evaluate whether the heterogeneity of tuber imaging features, evaluated on the structural imaging and apparent diffusion coefficient (ADC) map, can facilitate detecting epileptogenic tubers before surgery in tuberous sclerosis complex (TSC) patients. METHODS: Twenty-three consecutive patients, who underwent tuber resection at our institute, were retrospectively selected. A total of 125 tubers (39 epileptogenic, 86 non-epileptogenic) were used for the analysis. Tuber heterogeneity was evaluated, using a 5-point visual scale and standard deviation of ADC values (ADCsd). A 5-point visual scale reflected the degree of T1/T2 prolongation, presence of internal cystic degeneration, and their spatial distribution within the tuber. These results were statistically compared between epileptogenic and non-epileptogenic groups, and their performance in predicting the epileptogenicity was also evaluated by receiver operating characteristic (ROC) analysis. RESULTS: A 5-point visual scale demonstrated that more heterogeneous tubers were significantly more epileptogenic (p < 0.001). Multiplicity of internal cystic degeneration moderately correlated with epileptogenicity (p < 0.03) based on the comparison between class 4 and class 5 tubers. ADCsd was significantly higher in epileptogenic tubers (p < 0.001). ROC curves revealed that a 5-point visual scale demonstrated higher area under the curve (AUC) value than ADCsd (0.75 and 0.72, respectively). CONCLUSION: Tuber heterogeneity may help identify the epileptogenic tubers in presurgical TSC patients. Visual assessment and standard deviation of ADC value, which are easier to implement in clinical use, may be a useful tool predicting epileptogenic tubers, improving presurgical clinical management for TSC patients with intractable epilepsy.

Pulmonary metastases from angiosarcoma: a spectrum of CT findings.

BACKGROUND: Though a few reports have summarized the computed tomography (CT) findings of pulmonary metastases from angiosarcoma, the detailed CT findings of cysts are not well known, except for their characteristic thin walls. PURPOSE: To retrospectively summarize the CT findings of pulmonary metastases from angiosarcoma, focusing mainly on the CT findings of cysts. MATERIAL AND METHODS: Thirty-three patients with pulmonary metastases from angiosarcoma were selected retrospectively. Two radiologists reviewed and assessed patients' chest CT images on a consensus basis for nodules, cysts, the CT halo sign, pneumothorax, pleural effusion, and enlarged lymph nodes. Cysts were also evaluated by wall thickness and smoothness, air-fluid levels, and vessels or bronchi penetrating the cysts. The relationship between cysts and pneumothorax was assessed using the Chi-square test. RESULTS: Nodules were found in 28 (85%) patients. Cysts were found in 19 (58%) patients; 17 had thin and smooth walls, 10 had thin and irregular walls, and four had thick and irregular walls. In addition, 12 patients showed vessels or bronchi penetrating the cysts, and six showed air-fluid levels. The CT halo sign, pneumothorax, pleural effusion, and mediastinal lymphadenopathy were seen in 19 (58%), 16 (48%), 26 (78.8%), and five (15.2%) patients, respectively. Pneumothorax occurred significantly more frequently in patients with cysts (P = 0.002). CONCLUSION: Cysts showed variability in their walls, and air-fluid levels and vessels or bronchi penetrating the cysts appeared to be characteristic findings, which may be useful for detection and accurate diagnosis in patients with pulmonary metastases from angiosarcoma.

Evaluation of brain development and damage using magnetic resonance imaging of congenital diaphragmatic hernia survivors: An analysis using the global brain abnormality score.

BACKGROUND: The short-term prognosis of central nervous system in congenital diaphragmatic hernia (CDH) survivors has been determined by magnetic resonance imaging (MRI), but its relationship with acute management is unclear. We aimed to investigate the association between the intubation period and the Global Brain Abnormality Score (GBAS) in CDH survivors using brain MRI. METHODS: Fifty-seven patients with CDH who were hospitalized at a single NICU between January 2004 and December 2019 were retrospectively reviewed. After excluding 5 patients who died shortly after birth and two who could not be weaned from the ventilator, the acute management of the 50 remaining patients was investigated. We also investigated the relationship between the GBAS and intubation period in 25 patients who underwent brain MRI at discharge. RESULTS: The long-intubation group (intubation ≥12 days) had lower Apgar scores and fetal lung-thoracic ratios, and longer time to radical surgery, and parenteral nutrition and tube feeding periods. Nitric oxide inhalation, liver prolapse, patch closure, and extracorporeal membrane oxygenation were independent risk factors for long-intubation. Eighty-four percent of CDH survivors had some imaging abnormalities, including developmental and signaling abnormalities. In the long-intubation group, the body of the corpus callosum was thin and the cerebral hemispheric space was widened, and GBAS deterioration was significantly related to the intubation period. CONCLUSION: Brain MRI abnormalities were found in 84% of CDH survivors. Prolonged intubation is associated with worsening of the GBAS. Thus, the duration of intubation may be a surrogate outcome for the neurological prognosis of CDH survivors.

The effect of arterial spin labeling MR angiography (ASL-MRA) in visualizing the branches of external carotid artery.

This study aimed to assess the performance of arterial-spin labeling MRA (ASL-MRA) for visualizing the external carotid artery (ECA) branches in comparison with time-of-flight MRA (TOF-MRA) and CT angiography (CTA). We retrospectively selected 31 consecutive patients, who underwent both MRAs and CTA, prior to the intra-arterial chemoradiotherapy (IACRT) for head and neck cancer. Four patients underwent IACRT bilaterally, so we analyzed 35 ECAs. Pseudo-continuous, three-dimensional ASL using a turbo field echo sequence was acquired. For the TOF-MRA and CTA, clinically used parameters were applied. Two observers evaluated each ECA branch with reference to the angiogram at the IACRT, using five-point scale, in consensus. Friedman test for multiple comparisons was applied. ASL-MRA and CTA better visualized the superior thyroid, lingual, facial, submental, transverse facial, and internal maxillary arteries (IMAs) better than TOF-MRA (p < 0.05). In addition, CTA was superior to ASL-MRA in visualizing only submental artery among these arteries (p = 0.0005). Alternatively, the ASL-MRA was superior for visualizing the middle meningeal artery (MMA) and IMA, compared to the CTA (p = 0.0001 and 0.0007, respectively). ASL-MRA was superior to the TOF-MRA and similar to the CTA in visualizing most of ECA branches. Furthermore, ASL-MRA can better visualize the periphery of MMA and IMA than CTA.

Scintigraphy and computed tomography findings for the diagnosis of bronchiolitis obliterans following peripheral blood stem cell transplantation.

We report a case of bronchiolitis obliterans (BO) associated with allogenic peripheral blood stem cell transplantation for acute leukemia. On inspiratory and expiratory chest computed tomography (CT), characteristic findings for BO, such as air-trapping, mosaic attenuation or bronchial wall thickening were not clearly observed. However, ventilation-perfusion lung scans of the chest demonstrated multiple matched defects, which suggested severe obstructive airway disease. In the diagnosis of BO after stem cell transplantation, lung scans should be recommended when representative findings are not obvious on chest CT.

Primary diffuse leptomeningeal atypical teratoid rhabdoid tumor (AT/RT) demonstrating atypical imaging findings in an adolescent patient.

Atypical teratoid rhabdoid tumor (AT/RT) is a highly malignant central nervous system embryonal tumor, which typically affects the posterior fossa of young children. Primary diffuse leptomeningeal AT/RT, affecting the leptomeninges without any intraparenchymal mass in the brain and spinal cord, is an extremely rare form of AT/RT. Only 5 such cases have been reported previously, none of which underwent Fluorine-18-Fluorodeoxyglucose Positron Emission Tomography (FDG-PET). We herein report a case of primary leptomeningeal AT/RT in an adolescent patient who underwent computed tomography, magnetic resonance imaging and FDG-PET. The computed tomography and magnetic resonance imaging indicated diffusely thickened leptomeninges without any intraparenchymal masses in the head and spine. Furthermore, there were multiple nodules on the thickened leptomeninges. On FDG-PET, the thickened leptomeninges and nodules demonstrated a lower standardized uptake value than that of the normal cerebral cortex. Biopsy and histopathological studies confirmed the diagnosis of AT/RT. Despite its rare occurrence, it is important to recognize primary diffuse leptomeningeal AT/RT for correct diagnosis and management of patients.

A Neonatal Case of Mild Encephalopathy/Encephalitis with a Reversible Splenial Lesion.

The neurological symptoms of pediatric mild encephalopathy/encephalitis with a reversible splenial lesion (MERS) are mild and have a good prognosis. However, some aspects of neonatal MERS are unclear due to a lack of clinical knowledge. We present a neonatal case of MERS with features of poor activity and prolonged poor oxygenation after birth without asphyxia. He was diagnosed with MERS by brain magnetic resonance imaging (MRI) on day10, because the diffusion restriction of the splenium of the corpus callosum (SCC) seen on diffusion-weighted MRI on day 5 was attenuating. He was discharged due to good progress on day 26, but growth issues and developmental delay were observed in the follow up from 1-10 months. In rare neonatal cases, many aspects of the clinical course and prognosis are thus unclear. MERS should be considered in newborns who show unexplained non-neural or other encephalopathic symptoms.

Different indocyanine green fluorescence patterns of two skin metastases of hypopharyngeal squamous carcinoma: A case report.

BACKGROUND: Skin metastasis from primary squamous cell carcinoma of the head and neck is rare . These metastatic lesions are usually detected by physical examination, ultrasound imaging, computed tomography, and positron emission tomography.. Recently, indocyanine green fluorescence angiography (ICG-FA) has been used to discover superficial tumors. However, the optimum timing of ICG injection and fluorescence patterns of skin tumors in ICG-FA are still unknown. CASE PRESENTATION: We encountered a 60-year-old man with hypopharyngeal squamous cell carcinoma. The patient underwent concurrent chemotherapy, radiotherapy, and surgery. However, following these treatments, the patient developed two nodules in the skin of the right upper limb. Thus, the patient underwent ICG-FA. The two skin metastatic nodules showed different fluorescence patterns. One lesion showed high fluorescence intensity during ICG-FA. However, the fluorescence intensity of a small part of the other lesion exceeded that of the surrounding tissue only for a short time. CONCLUSION: We suggest that ICG-FA is effective for detecting skin metastases, and with further studies on the various fluorescence patterns of skin tumors, this technique will become more efficient.

(η-Benzene){2-[2-(tert-butyl-sulfan-yl)phenyl]pyridine-κN,S}chlorido-ruthenium(II) hexa-fluorido-phosphate.

In the title compound, [RuCl(C(6)H(6))(C(15)H(17)NS)]PF(6), the cation adopts a three-legged piano-stool structure around the Ru(II) atom with an η(6)-benzene ligand, a chloride ligand and a 2-[2-(tert-butyl-sulfan-yl)phen-yl]pyridine (btppy) ligand. The btppy ligand acts as a N,S-bidentate ligand, forming a six-membered ring, which has an envelope conformation. The S-Ru-N bite angle is 86.76 (9)°, and the dihedral angle between the pyridine and benzene rings in btppy is 39.8 (2)°. The unit cell contains two pairs of racemic diastereomers with (S(Ru),S(S)) and (R(Ru),R(S)) configurations, in which the tert-butyl group on the coordin-ated S atom is distant from the η(6)-benzene ligand.

Symptomatic jugular venous reflux with dilatation of the superior ophthalmic vein mimicking cavernous dural arteriovenous fistula.

We report a case of symptomatic jugular venous reflux (JVR) with dilatation of left superior ophthalmic vein (SOV), mimicking cavernous dural arteriovenous fistula (AVF). Severe JVR was caused by an AVFfor hemodialysis access and the narrowing of the left brachiocephalic vein. In-flow signals were found from the left internal jugular vein to left SOV on magnetic resonance angiography, and T1-weighted image and T2-weighted images demonstrated flow voids in bilateral sigmoid sinuses and confluence of sinuses due to rapid retrograde venous flow. We would like to emphasize that the presence of in-flow signals/flow voids in the venous sinuses may be the key imaging clues to distinguish JVR with dilatation of the SOV from cDAVF.

Percutaneous ipsilateral portal vein embolization using a modified four-lumen balloon catheter with fibrin glue: initial clinical experience.

PURPOSE: The purpose of the present study was to show the feasibility and safety of ipsilateral portal vein embolization (PVE) using an improved four-lumen balloon catheter with fibrin glue. MATERIALS AND METHODS: To improve the ipsilateral PVE with fibrin glue, we modified a commercially available four-lumen balloon catheter to create a catheter comprising one lumen with a catheter tip for a guidewire, one lumen for an occlusion balloon, and two lumens, each with a side-hole just proximal to the balloon. Eight patients had hepatobiliary disease (three with bile duct carcinoma, two with gallbladder carcinoma, one with hepatocellular carcinoma, one with Caroli disease, and one with metastatic carcinoma). RESULTS: All embolization procedures were technically successful. After embolization, the volume of the future remnant liver increased a mean of 131%. There was no inadvertent embolization of portal vein branches and no major procedure-related complications. CONCLUSION: Our method is potentially easier and safer than the traditional ipsilateral method with fibrin glue using a three-lumen balloon catheter because the fourth lumen makes possible the use of a guidewire to access the targeted portal vein and measurement of any portal vein pressure elevation following PVE via the fourth lumen.

Use of Diffusion Weighted Imaging in Differentiating Between Maligant and Benign Meningiomas. A Multicenter Analysis.

BACKGROUND: Meningioma is the most frequent intracranial tumor and is often an incidental finding on imaging. Some imaging-based scores were suggested for differentiating low- and high-grade meningiomas. The purpose of this work was to compare diffusion-weighted imaging findings of different meningiomas in a large multicenter study by using apparent diffusion coefficient (ADC) values for predicting tumor grade and proliferation potential. METHODS: Data from 7 radiologic departments were acquired retrospectively. Overall, 389 patients were collected. All meningiomas were investigated by magnetic resonance imaging (1.5-T scanner) by using diffusion-weighted imaging (b values of 0 and 1000 s/mm(2)). The comparison of ADC values was performed by Mann-Whitney U test. RESULTS: World Health Organization grade I was diagnosed in 271 cases (69.7%), grade II in 103 (26.5%), and grade III in 15 patients (3.9%). Grade I meningiomas showed statistically significant higher ADC values (1.05 ± 0.39 × 10(-3) mm(2)s(-1)) in comparison with grade II (0.77 ± 0.15 × 10(-3) mm(2)s(-1); P = 0.001) and grade III tumors (0.79 ± 0.21 × 10(-3) mm(2)s(-1); P = 0.01). An ADC value of <0.85 × 10(-3) mm(2)s(-1) was determined as the threshold in differentiating between grade I and grade II/III meningiomas (sensitivity, 72.9%; specificity, 73.1%; accuracy, 73.0%). Ki67 was associated with ADC (r = -0.63, P < 0.001). The optimal threshold for the ADC was (less than) 0.85 × 10(-3) mm(2)s(-1) for detecting tumors with high proliferation potential (Ki67 ≥5%). CONCLUSIONS: The estimated threshold ADC value of 0.85 can differentiate grade I meningioma from grade II and III tumors. The same ADC value is helpful for detecting tumors with high proliferation potential.

Topographical Distribution of Epileptogenic Tubers in Patients With Tuberous Sclerosis Complex.

Tuberous sclerosis complex is a multisystem genetic syndrome often affecting the central nervous system. The purpose of the current study was to identify topographical patterns in the distribution specific to epileptogenic (n = 37) and nonepileptogenic (n = 544) tubers throughout the brain for a cohort of 23 tuberous sclerosis complex patients with a history of seizures. Tubers localized to the inferior parietal lobes, middle frontal lobes, middle temporal lobes, or central sulcus regions were associated with a high frequency of epileptogenic tubers. Epileptogenic tubers occurred statistically more frequently within the inferior parietal lobe and within the central sulcus region in children younger than 1 or between 1 and 3 years old, respectively. Results imply seizure activity in tuberous sclerosis complex patients can be associated with the location of cortical tubers.

DTI of tuber and perituberal tissue can predict epileptogenicity in tuberous sclerosis complex.

OBJECTIVE: To evaluate whether diffusion tensor imaging (DTI) can predict epileptogenic tubers by measuring apparent diffusion coefficient (ADC), fractional anisotropy, axial diffusivity, and radial diffusivity in both tubers and perituberal tissue in pediatric patients with tuberous sclerosis complex (TSC) undergoing epilepsy surgery. METHODS: We retrospectively selected 23 consecutive patients (aged 0.4-19.6 years, mean age of 5.2; 13 female, 10 male) who underwent presurgical DTI and subsequent surgical resection between 2004 and 2013 from the University of California-Los Angeles TSC Clinic. We evaluated presurgical examinations including video-EEG, brain MRI, (18)F-fluorodeoxyglucose-PET, magnetic source imaging, and intraoperative electrocorticography for determining epileptogenic tubers. A total of 545 tubers, 33 epileptogenic and 512 nonepileptogenic, were identified. Two observers generated the regions of interest (ROIs) of tubers (ROI(tuber)), the 4-mm-thick ring-shaped ROIs surrounding the tubers (ROI(perituber)), and the combined ROIs (ROI(tuber+perituber)) in consensus and calculated maximum, minimum, mean, and median values of each DTI measure in each ROI for all tubers. RESULTS: The Mann-Whitney U test demonstrated that the epileptogenic group showed higher maximum ADC and radial diffusivity values in all ROIs, and that maximum ADC in ROI(tuber+perituber) showed the strongest difference (p = 0.001). Receiver operating characteristic analysis demonstrated that maximum ADC measurements in ROI(tuber+perituber) (area under curve = 0.68 ± 0.05, p < 0.001) had 81% sensitivity and 44% specificity for correctly identifying epileptogenic tubers with a cutoff value of 1.32 µm(2)/ms. CONCLUSIONS: DTI analysis of tubers and perituberal tissue may help to identify epileptogenic tubers in presurgical patients with TSC more easily and effectively than current invasive methods.

Usefulness of the apparent diffusion coefficient (ADC) for predicting the consistency of intracranial meningiomas.

Meningioma consistency is an important factor for surgical treatment. Tumor cellularity and fibrous tissue contribute to the consistency of tumors, and it is proposed that the minimum apparent diffusion coefficient (ADC) value is significantly correlated with meningioma consistency. Twenty-seven consecutive patients with 28 meningiomas were retrospectively enrolled. Minimum ADC values in meningiomas with a hard consistency were significantly lower than those with a soft consistency. The minimum ADC value might have clinical use as a predictor of meningioma consistency.

Distribution patterns of metastatic pelvic lymph nodes assessed by CT/MRI in patients with uterine cervical cancer.

BACKGROUND: To investigate the three-dimensional (3D) distribution patterns of clinically metastatic (positive) lymph nodes on pretreatment computed tomography (CT)/magnetic resonance imaging (MRI) images of patients with locally advanced cervical cancer. METHODS: We enrolled 114 patients with uterine cervical cancer with positive nodes by CT/MRI (≥10 mm in the shortest diameter). Pretreatment CT/MRI data were collected at 6 institutions. The FIGO stage was IB1 in 2 patients (2%), IB2 in 6 (5%), IIA in 3 (3%), IIB in 49 (43%), IIIB in 50 (44%), and IVA in 4 (4%) patients. The median cervical tumor diameter assessed by T2-weighted MRI was 55 mm (range, 10-87 mm). The anatomical distribution of the positive nodes was evaluated on CT/MRI images by two radiation oncologists and one diagnostic radiologist. RESULTS: In these patients, 273 enlarged nodes were assessed as positive. The incidence of positive nodes was 104/114 (91%) for the obturator region, 31/114 (27%) for the external iliac region, 16/114 (14%) for the internal iliac region, 22/114 (19%) for the common iliac region, and 6/114 (5%) for the presacral region. The external iliac region was subdivided into four sub-regions: lateral, intermediate, medial, and caudal. The obturator region was subdivided into two sub-regions: cranial and caudal. The majority of patients had positive nodes in the cranial obturator and/or the medial external iliac region (111/114). In contrast, few had positive nodes in the lateral external iliac, caudal external iliac, caudal obturator, internal iliac and presacral regions. All cases with positive nodes in those low-risk regions also had positive nodes in other pelvic nodal regions concomitantly. The incidence of positive nodes in the low-risk regions/sub-regions was significantly related to FIGO stage (p=0.017) and number of positive nodes (p<0.001). CONCLUSIONS: We demonstrated the 3D distribution patterns of clinical metastatic pelvic lymph nodes on pretreatment CT/MRI images of patients with locally advanced cervical cancer. These findings might contribute to future individualization of the clinical target volume of the pelvic nodes in patients with cervical cancer.

Effectiveness of subcutaneous growth hormone in HIV-1 patients with moderate to severe facial lipoatrophy.

OBJECTIVE: To evaluate effect of recombinant human growth hormone (rhGH) among HIV-infected adults with moderate to severe facial lipoatrophy as a side effect of long-term antiretroviral treatment. DESIGN: A prospective open-label study METHODS: Twenty-five HIV-1 patients with moderate to severe facial lipoatrophy who had been on antiretroviral treatment for more than 18 months were enrolled. rhGH (5 mg) was given every other day for 6 months. After treatment was completed, the participants were followed up for 6 months. Facial lipoatrophy was evaluated by computed tomography at months 0, 3, 6 and 12. RESULTS: Nearly all participants (24 of 25) completed the study. The sum of bilateral soft tissue thickness at the level of zygomatics at months 0, 3, 6, 12 were 7.23, 8.59, 8.35, 8.60 mm, respectively. There was significant improvement from baseline in month 3 (p=0.009) and month 12 (p=0.021). In the 6 months of follow-up, the soft tissue showed no significant decrease. Several side effects including diarrhea, arthralgia, myalgia, mastalgia and hand numbness were seen, which were self-limited and transient. CONCLUSION: rhGH is effective and relatively safe for moderate to severe facial lipoatrophy. Its effect was sustained at least for 6 months after the cessation of rhGH.