Comparison of arterial spin labeling and dynamic susceptibility contrast perfusion MR imaging in pediatric brain tumors: A systematic review and meta-analysis.

BACKGROUND: Brain tumors are a leading cause of mortality in children. Accurate tumor grading is essential to plan treatment and for prognostication. Perfusion imaging has been shown to correlate well with tumor grade in adults, however there are fewer studies in pediatric patients. Moreover, there is no consensus regarding which MR perfusion technique demonstrates the highest accuracy in the latter population. PURPOSE: To compare the diagnostic test accuracy of dynamic-susceptibility contrast and arterial spin-labelling, in their ability to differentiate between low-and high-grade pediatric brain tumors at first presentation. DATA SOURCES: Articles were retrieved from online electronic databases: MEDLINE (Ovid), Web of Science Core Collection and SCOPUS. STUDY SELECTION: Studies in pediatric patients with a treatment naïve diagnosed brain tumor and imaging including either ASL or DSC or both, together with a histological diagnosis were included. Studies involving adult patient or mixed age populations, studies with incomplete data and those which used dynamic contrast enhanced perfusion were excluded. DATA ANALYSIS: The sensitivities and specificities obtained from each study were used to calculate the true-positive, true-negative, false-positive, and false-negative count. A case was defined as a histologically proven high-grade tumor. The random-effect model was used to merge statistics. Significance level was set at p < 0.05. DATA SYNTHESIS: Forest plots showing pairs of sensitivity and specificity, with their 95% confidence intervals, were constructed for each study. The bivariate model was applied in order to account for between-study variability. The SROC plots were constructed from the obtained data-sets. The AUC for the SROC of all studies was estimated to determine the overall diagnostic test accuracy of perfusion MRI, followed by a separate comparison of the SROC of ASL versus DSC studies. LIMITATIONS: Small and heterogenous sample size. CONCLUSIONS: The diagnostic accuracy of ASL was found to be comparable and not inferior to DSC, thus its use in the diagnostic assessment of pediatric patients should continue to be supported. ABBREVIATIONS: ASL = arterial spin labelling, DSC = dynamic susceptibility contrast, DCE = dynamic contrast-enhanced, rCBF = relative cerebral blood flow, rCBV = relative cerebral blood volume, MTT = mean transfer time, TR = repetition time, TE = echo time, SROC = summary receiver operating characteristics, HG= high-grade, LG = low-grade, AUC = area under the curve, PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

The Chronically Blocked Ear - A dive into external auditory exostosis.

Numerous papers have reported the presence of reactive but benign bony exostosis in the external auditory canal of swimmers; of both cold and warm water. This outgrowth may lead to stenosis of the canal with associated complications such as repeated cerumen impaction, infections and also hearing loss. In this case report, we will present the case of a 62-year-old gentleman who was referred for imaging by an ENT specialist following difficulty with visualisation of the tympanic membrane during otoscopy.

Outcomes of endovascular treatment for acute ischaemic stroke in Mater Dei Hospital, Malta.

INTRODUCTION: The aim of this study was to assess the outcomes of endovascular treatment for acute ischaemic stroke in Mater Dei Hospital, Malta and compare them with international data. METHODS: A prospective review of all patients who underwent mechanical thrombectomy from 2015 to the end of 2019 was performed. Eligible patients had large vessel occlusion confirmed on computed tomography angiography. Demographical data, the National Institutes of Health stroke scale at presentation, endovascular procedure details and process times were analysed. The thrombolysis in cerebral infarction score was used to assess the degree of reperfusion. A thrombolysis in cerebral infarction score of 2b-3 was considered as successful recanalisation. Functional outcome (modified Rankin scale score) and mortality at 90 days were measured. Functional independence was defined as a modified Rankin scale score of 2 or less. RESULTS: A total of 132 patients underwent endovascular treatment, one patient was excluded due to incomplete data. The mean age was 71 (range 25-94) years, and the mean National Institutes of Health stroke scale at presentation was 14. Of the 131 patients treated, 69 received intravenous thrombolysis. Successful recanalisation (thrombolysis in cerebral infarction score 2b-3) was achieved in 80% of patients (105/131); 53% of patients (69/131) achieved functional independence at 90 days, with a mortality of 21% at 90 days. Symptomatic intracranial haemorrhage was recorded in 16 patients (12%) There was a statistical difference in the functional independence and mortality rate in favour of the successful recanalisation group. CONCLUSION: Our data are consistent with a favourable clinical outcome after successful recanalisation. Service in Malta is achieving favourable outcomes for patients treated with mechanical thrombectomy for acute ischaemic stroke.

Covid-19 Restrictive Measures: A Theoretical Exploration of Defiant Attitudes.

The aim of this paper is to explore defiant attitudes to Covid-19 restrictions against a backdrop of Health Behaviour Theories, so as to gain further understanding of such behaviour and target it accordingly. In an attempt to limit the mortality and morbidity of the pandemic, health authorities are encouraging and enforcing the adherence to restrictive measures. Still, defiant attitudes persist. Possible reasons for these attitudes include an unappreciation of possible consequences and feelings of helplessness. The psychiatric nurse has a specific toolkit that is crucial in addressing these thought processes and behaviours-this shall be explored.

The role of health promotion theories in Stroke Awareness and Education.

The aim of this paper is to provide an overview of health promotion theories and their application to Stroke Awareness and Education. Stroke stands as one of the leading causes of mortality and morbidity even though treatment is readily available. One of the major challenges in this area is that the effectiveness of treatment depends heavily on timely presentation to healthcare services. Unfortunately, many individuals do not seek help whilst experiencing symptoms or only do so after a significant delay. This paper explores the main health promotion theories related to this problematic health behaviour in relation to stroke.

Highlighting the classical MRI findings in transient global amnesia.

Transient global amnesia (TGA) is a disorder characterised by a temporary, reversible disruption of short-term memory. While the diagnosis of TGA is based on its clinical features, neuroimaging is important to exclude other sinister causes of global amnesia. Furthermore, classical MRI changes in TGA have been well described in the literature. These consist of unilateral or bilateral punctuate areas of hyperintensity in the hippocampal cornu ammonis 1 (CA1) region on diffusion-weighted imaging. We describe a case of a 61-year-old gentleman, presenting with symptoms of transient memory loss and confusion. A stroke was initially suspected in view of his multiple risk factors. Timely MRI demonstrated the typical findings associated with TGA. Recognition of these imaging features is of the utmost importance for radiologists in order to allow for an accurate diagnosis and differentiation from ischaemic pathology.

COVID-19 in Malta: The mental health impact.

The COVID-19 pandemic has had a devastating impact on health, economies, and other societal pillars. The Maltese archipelago has also been affected by this viral threat. Due to Malta's characteristics as one of the smallest islands in Europe, the picture, which shall be portrayed in this article, may have some unique features, especially in terms of mental health and societal well-being. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Comparison of Narrative Exposure Therapy and Non-Trauma-Focused Treatment in Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis.

Background: Narrative Exposure Therapy (NET) is a relatively new treatment that may be beneficial as a standalone approach or as an adjunct for use in individuals who suffer from simple or complex Posttraumatic Stress Disorder (PTSD).Aims: The main objective of this review was to explore the effectiveness of NET in remediating PTSD symptoms as compared to Non Trauma-Focused-Therapy (NTFT).Methods: A systematic search in Medline, PsycINFO, EMBASE and The Cochrane Central Register of Controlled Trials (CENTRAL) was carried out. Reference lists of papers and grey literature were hand searched. Experimental studies that compare NET to NTFT with no preference to age, gender or nationality of participants that include a baseline and 3-6 month measurement of PTSD outcomes using tools with good psychometric properties were included. The search resulted in 10 randomised controlled trials. Data extraction, collection and analysis was then carried out by the authors.Results: In all of the studies, the difference in the PTSD symptoms' mean score after 3-6 months between the NET group and the NTFT group was in favour of NET. However, the level of significance was attained in six of the studies only. The overall effect size (standardised mean difference) of the trials is 0.684 in favour of NET (p < .001).Conclusions: NET was shown to be superior to NTFT in post-traumatic stress disorder. The most important recommendations are in relation to research and target the methodological limitations of existing studies in particular the small sample sizes, lack of blindness and inadequate rigour during the trials. More research is needed to further explore the benefits of NET for different populations and trauma-types.

Multinodular and Vacuolating Neuronal Tumor.

BACKGROUND: Multinodular and Vacuolating Neuronal Tumor (MVNT) of the cerebrum is a benign lesion described recently in the WHO CNS tumours in 2016. Although this tumour is uncommon, clinicians should be acquainted with the possible presentation and imaging findings. CASE REPORT: We present a case of a young gentleman whose only symptom was absence seizures. Brain imaging showed lesions, compatible with this rare diagnosis. CONCLUSION: Our description of imaging findings on MRI highlights the characteristic cystic appearances of note in the right occipital lobe, in contrast to the temporal lobe as the predominant location found in previous cases.

Highlighting an atypical cause of the Face of the Giant Panda sign.

The "Face of the Giant Panda" and the "Panda Cub" signs are neuroimaging features originally described in patients with Wilson's disease. We present a case with similar imaging findings in a different clinical context and highlight other differential diagnoses to be considered when presented with this particular radiological sign.

Stent-based thrombectomy versus intravenous tissue plasminogen activator in acute ischaemic stroke: A systematic review and meta-analysis.

PURPOSE: To date only a few studies have compared the effectiveness and functional outcomes of stent retrievers versus intravenous thrombolysis in acute ischaemic stoke. Our aim was to identify and collate all the available data and to assess for statistical differences in patient outcomes between the two treatments. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of studies with a randomised controlled design which utilised stentrievers and intravenous thrombolysis in acute ischaemic stroke. RESULTS: Five randomised controlled studies published in 2015 were identified. Second-generation thrombectomy devices constituted at least 80% of thrombectomy devices in the included studies, namely MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and REVASCAT. No significant heterogeneity was seen in the included studies and the five trials were therefore included in the meta-analysis.A total of 46.10% of patients treated with stentrievers achieved an independent functional outcome (mRS < 2) at 90 days compared with 26.46% of those treated with intravenous thrombolysis with an odds ratio of 2.40 (p < 0.001). The weighted recanalisation mean in the thrombectomy arms was 76.02%.A lower mortality rate was observed with stentrievers compared to intravenous thrombolysis (15.33% vs 18.74%; OR 0.81, p = 0.15). Stentrievers were also associated with a lower risk of symptomatic intracranial haemorrhage (7.86% vs 8.64%; OR 1.02, p = 0.93). The differences in the secondary/safety outcomes were not statistically significant. CONCLUSION: Stentrievers can achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. Our meta-analysis demonstrates a clear benefit of an intra-arterial mechanical approach vs standard treatment.