Neuropathologically informed imaging of cortical grey matter lesions in MS - A pilot study.

Multiple sclerosis (MS) is frequently misdiagnosed based on MRI abnormalities detected in the brain white matter. Cortical lesions have been well described neuropathologically, but remain challenging to detect in clinical practice. Therefore, the ability to detect cortical lesions offers real potential to reduce misdiagnosis. Cortical lesions have been shown to have a predilection for regions with CSF stasis - such as the insula and cingulate gyrus. This pathological observation forms the basis of our current pilot MR imaging study, which successfully uses high spatial resolution imaging of these two anatomical regions to clearly identify cortical lesions in MS.

Characteristics and outcomes of acute colitis diagnosed on cross-sectional imaging presenting via the emergency department in an Irish academic medical centre.

BACKGROUND AND AIMS: A significant proportion of patients presenting to the Emergency Department with gastrointestinal symptoms that result in cross-sectional imaging receive a radiological diagnosis of colitis. We aimed to review the characteristics, outcomes, and final diagnoses of new emergency department presentations with colitis diagnosed on cross-sectional imaging. METHODS: A radiology database was interrogated to identify patients admitted from the Emergency Department of St James's Hospital whose cross-sectional imaging demonstrated colitis. Baseline demographic data, information on inpatient investigations, final diagnoses, and outcomes were recorded. Adverse outcomes were defined as a requirement for surgery, intensive care unit (ICU) stay, or mortality RESULTS: A total of 118 patients, 67% female, were identified with a median age of 64 years (range 16.9-101.2). Median (range) admission duration was 10 days (1-241). Final colitis diagnoses were infectious (28%), undefined (27%), reactive (18%), inflammatory bowel disease (11%), ischaemic (9%), chemotherapy-associated (3%), diverticular (3%), and medication-associated (1%). Colonic perforation, colectomy, and mortality occurred in 1%, 5%, and 13% of the cohort respectively. On univariate analysis, low haemoglobin, low albumin, high lactate, and male gender were associated with adverse outcomes with the following odds ratios (OR) and 95% confidence intervals (95%CI) were low haemoglobin 1.49 [1.15-1.92] P = 0.002, low albumin 1.16 [1.07-1.25] P = 0.0002, lactate 1.65 [1.13-2.42] P = 0.009, and male gender 3.09 [1.23-7.77] P = 0.019. On multivariate analysis, male gender was associated with adverse outcomes. CONCLUSION: Patients presenting to the Emergency Department with a colitis, requiring an abdominal CT are a heterogenous group with a proportion having concomitant intra-abdominal pathology resulting in critical illness. Hence their is a significant morbidity and mortality observed in this cohort which should not be extrapolated to a general population of patients presenting with colitis. In this cohort of patients, anaemia, hypoalbuminaemia, and elevated lactate in patients presenting to the ED with acute colitis are significantly associated with adverse outcomes. Early recognition of these prognostic factors may identify the cohort of patients who are best managed in a high-dependency setting.

Relationship between 'on-treatment platelet reactivity', shear stress, and micro-embolic signals in asymptomatic and symptomatic carotid stenosis.

BACKGROUND: Assessment of 'high on-treatment platelet reactivity (HTPR)' could enhance understanding of the pathophysiology of first or recurrent vascular events in carotid stenosis patients on antiplatelet therapy. METHODS: This prospective, multi-centre study assessed antiplatelet-HTPR status and its relationship with micro-emboli signals (MES) in asymptomatic vs. symptomatic ≥ 50-99% carotid stenosis. Platelet function/reactivity was assessed under 'moderately high shear stress' with the PFA-100® and 'low shear stress' with VerifyNow® and Multiplate® analysers. Bilateral 1-h transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES + ve or MES - ve. RESULTS: Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the 'early phase' (≤ 4 weeks) and 37 patients in the 'late phase' (≥ 3 months) after TIA/ischaemic stroke. Median daily aspirin doses were higher in early symptomatic (225 mg; P < 0.001), but not late symptomatic (75 mg; P = 0.62) vs. asymptomatic patients (75 mg). There was a lower prevalence of aspirin-HTPR in early (28.6%; P = 0.028), but not late symptomatic (38.9%; P = 0.22) compared with asymptomatic patients (56.7%) on the PFA-100®, but not on the VerifyNow® or Multiplate® (P ≤ 0.53). Early symptomatic patients had a higher prevalence of aspirin-HTPR on the PFA-100® (28.6%) vs. VerifyNow® (9.5%; P = 0.049), but not Multiplate® assays (11.9%, P = 0.10). There was no difference in aspirin-HTPR prevalence between any symptomatic vs. asymptomatic MES + ve or MES - ve subgroup. DISCUSSION: Recently symptomatic moderate-severe carotid stenosis patients had a lower prevalence of aspirin-HTPR than their asymptomatic counterparts on the PFA-100®, likely related to higher aspirin doses. The prevalence of antiplatelet-HTPR was positively influenced by higher shear stress levels, but not MES status.

Portal Hypertensive Colopathy with Pelvic Varices presenting as Severe Lower GI Bleed treated with TIPSS.

We present the case of a 71-year-old lady with a background of significant alcohol intake who presented with frank lower gastrointestinal (GI) bleeding, lower abdominal pain and haemoglobin 6.3g/dL. CT abdominal angiogram showed right-sided colonic thickening, atrophic liver and enlarged superior mesenteric vein (SMV) and right-sided pelvic varix. This lead to a diagnosis of portal hypertensive colopathy secondary to alcoholic liver cirrhosis. The patient failed conservative management and underwent a Transjugular Intrahepatic Portosystemic Shunt (TIPSS) procedure. This lead to an immediate resolution of her lower-GI bleeding. Repeat CT at three weeks showed a decompressed SMV and resolution of the right-sided pelvic varix. The patient was discharged after three months following optimization of medical condition and social circumstances.

Effectiveness of a low support, remotely accessible, cognitive remediation training programme for chronic psychosis: cognitive, functional and cortical outcomes from a single blind randomised controlled trial.

BACKGROUND: Cognitive remediation (CR) training has emerged as a promising approach to improving cognitive deficits in schizophrenia and related psychosis. The limited availability of psychological services for psychosis is a major barrier to accessing this intervention however. This study investigated the effectiveness of a low support, remotely accessible, computerised working memory (WM) training programme in patients with psychosis. METHODS: Ninety patients were enrolled into a single blind randomised controlled trial of CR. Effectiveness of the intervention was assessed in terms of neuropsychological performance, social and occupational function, and functional MRI 2 weeks post-intervention, with neuropsychological and social function again assessed 3-6 months post-treatment. RESULTS: Patients who completed the intervention showed significant gains in both neuropsychological function (measured using both untrained WM and episodic task performance, and a measure of performance IQ), and social function at both 2-week follow-up and 3-6-month follow-up timepoints. Furthermore, patients who completed MRI scanning showed improved resting state functional connectivity relative to patients in the placebo condition. CONCLUSIONS: CR training has already been shown to improve cognitive and social function in patient with psychosis. This study demonstrates that, at least for some chronic but stable outpatients, a low support treatment was associated with gains that were comparable with those reported for CR delivered entirely on a 1:1 basis. We conclude that CR has potential to be delivered even in services in which psychological supports for patients with psychosis are limited.

Horizontal nystagmus and multiple sclerosis using 3-Tesla magnetic resonance imaging.

BACKGROUND: Nystagmus in patients with multiple sclerosis (MS) is generally attributed to brainstem disease. Lesions in other regions may result in nystagmus. The identification of these other sites is enhanced by using 3-Tesla magnetic resonance imaging (3TMRI) due to increased signal-to-noise ratio. OBJECTIVE: We sought to evaluate the distribution of structural lesions and disruption of tracts in patients with horizontal nystagmus secondary to MS using 3TMRI. METHODS: Twenty-four patients (20 women, 4 men; age range 26-55 years) with horizontal nystagmus secondary to MS underwent 3TMRI brain scans; and 18 patients had diffusion tensor imaging (DTI) for tractography. RESULTS: Nystagmus was bidirectional in 11, right-sided in 6 and left-sided in 7. We identified 194 lesions in 20 regions within the neural integrator circuit in 24 patients; 140 were within the cortex and 54 were within the brainstem. Only two patients had no lesions in the cortex, and 9 had no lesions in the brainstem. There was no relationship between side of lesion and direction of nystagmus. Thirteen of 18 (72 %) had tract disruption with fractional anisotropy (FA) values below 0.2. FA was significantly lower in bidirectional compared to unidirectional nystagmus (p = 0.006). CONCLUSION: In MS patients with horizontal nystagmus, lesions in all cortical eye fields and their descending connections were evident. Technical improvements in tractography may help identify the specific site(s) resulting in nystagmus in MS.

Ischaemic stroke or TIA in older subjects associated with impaired dynamic blood pressure control in the absence of severe large artery stenosis.

BACKGROUND: older subjects may require higher baseline blood pressures to maintain cerebral perfusion. We investigated whether episodic hypotension is associated with tissue infarction in subjects with syncopal symptoms at stroke onset. METHODS: over 30 months, all acute strokes/TIAs were prospectively screened for symptoms of syncope or presyncope at stroke onset. Subjects with severe large vessel stenosis were excluded, while cases were referred for syncope unit investigation. All underwent 1.5 T MRI acutely, and suspected borderzone infarctions (BZI) were confirmed through Matlab-derived perfusion software. Case-control comparison was derived from stroke controls with no prior syncope history. RESULTS: thirty-eight of 772 stroke patients described presyncope or syncope at stroke onset and had patent large vessels (4.9% of all strokes). Median age was 72 years (IQR 21.4). Twenty-two patients (58%) were prescribed antihypertensive agents at symptom onset. Twenty-six (68.4%) reported focal neurology <24 h in duration. 63.2% (n = 24) of cases reported prior syncope history, compared with 33% (N = 103) of controls, P < 0.001. Cases exhibited greater orthostatic BP drop than controls, P < 0.05 Twenty-four patients were diagnosed with vasovagal syncope through head-up tilt symptom reproduction, 9 with orthostatic hypotension, 4 with cardiac syncope and 1 with carotid sinus syndrome. Nineteen (50%) patients had an acute infarct on MRI, 14 of these were in the arterial borderzone (73.6%). The BZI group were significantly older than the non-BZI group, 79.2 yrs versus 63.3 yrs, P = 0.002. CONCLUSION: subjects reporting hypotensive symptoms at stroke onset have a higher prevalence of borderzone infarction, despite being normotensive or hypertensive at baseline.

Syncope causes transient focal neurological symptoms.

AIMS: The prevalence of focal neurology (FN) as a consequence of syncope is unknown. The aim of the study was to determine its prevalence, risk factors and short-term consequences. METHODS: A consecutive sample of syncope-unit attendees during a 9-month period had detailed diagnostic syncope evaluation as per European Cardiac Society guidelines coupled with assessment for FN present during syncope/pre-syncope by screening questionnaire, follow-up interview and neuroimaging (1.5T magnetic resonance imaging [MRI]). All participants were followed up for 24 months. Risk factors for FN were identified by comparing FN cases with syncope controls without FN (3:1 ratio). RESULTS: Five-hundred and forty consecutively attended for investigation of syncope (n = 401) and pre-syncope (n = 139). Thirty-one (5.7%) had FN events during hypotensive symptoms, mean age 49 years (19-85). The majority of FN cases had vasovagal syncope (VVS); 22 (71%), whereas eight had OH (25.8%) and one (3.2%) had cardiac arrhythmia. Median duration of FN was 15 min (IQR: 34.5). MRI in 28 (90%) was normal and in 3, old cerebral infarction was evident. Risk factors for FN/syncope were frequent syncope (P = 0·008), childhood syncope (P < 0.0005) and delayed diastolic recovery during active stand (P = 0·02). During 24-month follow-up and targeted intervention, no patients developed recurrence of FN. CONCLUSION: One in 20 patients with syncope/pre-syncope have co-extant FN, which during 24-month follow-up, does not progress to a persistent deficit (>24 h). Awareness of co-occurrence of FN and syncope is important as stroke misdiagnosis results in aggressive anti-hypertensive management and future events may ensue.

Reduced expression of glucocorticoid-inducible genes GILZ and SGK-1: high IL-6 levels are associated with reduced hippocampal volumes in major depressive disorder.

Neuroplasticity may have a core role in the pathophysiology of major depressive disorder (MDD), a concept supported by experimental studies that found that excessive cortisol secretion and/or excessive production of inflammatory cytokines impairs neuronal plasticity and neurogenesis in the hippocampus. The objective of this study was to examine how changes in the glucocorticoid and inflammatory systems may affect hippocampal volumes in MDD. A multimodal approach with structural neuroimaging of hippocampus and amygdala, measurement of peripheral inflammatory proteins interleukin (IL)-6 and C-reactive protein (CRP), glucocorticoid receptor (GR) mRNA expression, and expression of glucocorticoid-inducible genes (glucocorticoid-inducible genes Leucin Zipper (GILZ) and glucocorticoid-inducible kinase-1 (SGK-1)) was used in 40 patients with MDD and 43 healthy controls (HC). Patients with MDD showed smaller hippocampal volumes and increased inflammatory proteins IL-6 and CRP compared with HC. Childhood maltreatment was associated with increased CRP. Patients with MDD, who had less expression of the glucocorticoid-inducible genes GILZ or SGK-1 had smaller hippocampal volumes. Regression analysis showed a strong positive effect of GILZ and SGK-1 mRNA expression, and further inverse effects of IL-6 concentration, on hippocampal volumes. These findings suggest that childhood maltreatment, peripheral inflammatory and glucocorticoid markers and hippocampal volume are interrelated factors in the pathophysiology of MDD. Glucocorticoid-inducible genes GILZ and SGK-1 might be promising candidate markers for hippocampal volume changes relevant for diseases like MDD. Further studies need to explore the possible clinical usefulness of such a blood biomarker, for example, for diagnosis or prediction of therapy response.

Reduced fractional anisotropy in the uncinate fasciculus in patients with major depression carrying the met-allele of the Val66Met brain-derived neurotrophic factor genotype.

Experimental studies support a neurotrophic hypothesis of major depressive disorder (MDD). The aim of this study was to determine the effect of Val66Met brain-derived neurotrophic factor (BDNF) polymorphism on the white matter fiber tracts connecting hippocampus and amygdala with the prefrontal lobe in a sample of patients with MDD and healthy controls. Thirty-seven patients with MDD and 42 healthy volunteers were recruited. Diffusion tensor imaging (DTI) data with 61 diffusion directions were obtained with MRI 3 Tesla scanner. Deterministic tractography was applied with ExploreDTI and Val66Met BDNF SNP (rs6265) was genotyped. Fiber tracts connecting the hippocampus and amygdala with the prefrontal lobe, namely uncinate fasciculus (UF), fornix, and cingulum were analyzed. A significant interaction was found in the UF between BDNF alleles and diagnosis. Patients carrying the BDNF met-allele had smaller fractional anisotropy (FA) in the UF compared to those patients homozygous for val-allele and compared to healthy subjects carrying the met-allele. A significant three-way interaction was detected between region of the cingulum (dorsal, rostral, and parahippocampal regions), brain hemisphere and BDNF genotype. Larger FA was detectable in the left rostral cingulum for met-allele carriers when compared to val/val alelle carriers. We provide evidence for the importance of the neurotrophic involvement in limbic and prefrontal connections. The met-allele of the BDNF polymorphism seems to render subjects more vulnerable for dysfunctions associated with the UF, a tract known to be related to negative emotional-cognitive processing bias, declarative memory problems, and autonoetic self awareness.

Hybrid repair of a symptomatic thoracic intra-mural haematoma.

INTRODUCTION: The repair of thoracic aortic pathology by open techniques is associated with high morbidity and mortality. METHODS: We describe the first case of hybrid thoracic aortic repair performed in Ireland for a symptomatic thoracic intramural haematoma. CONCLUSION: Hybrid repair with extra-anatomical aortic visceral revascularisation and subsequent thoracic endograft exclusion offers an attractive alternative method of repair for thoracic aortic pathology.

Piriformis pyomyositis, an unusual presentation of leg pain post partum--case report and review of literature.

Piriformis pyomyositis is defined as a subacute infection of skeletal muscles associated with systemic infectious symptoms. In the literature it rarely occurs postpartum. We report a case of piriformis pyomyositis involving a parturient and review the published cases available in the literature.

Tracheoesophageal compression associated with substernal goitre. Correlation of symptoms with cross-sectional imaging findings.

OBJECTIVE: The aim of this study was to compare the subjective tracheoesophageal pressure symptoms associated with substernal goitres with objective cross-sectional radiographic measurements. DESIGN: Patients with substernal goitre were questioned regarding tracheoesophageal compression symptoms and these data were analysed for correlation with radiographic and intra-operative findings. RESULTS: Twenty-six patients were included. Patients with airway symptoms including dyspnoea, stridor and coughing were more likely to have significant tracheal narrowing on pre-operative computed tomography (CT) imaging. There was also a significant correlation between the perceived severity of lump sensation in the throat and the presence of tracheal and oesophageal displacement and retrotracheal extension of the thyroid mass. CONCLUSION: Pre-operative CT measurements of tracheal and oesophageal displacement, retrotracheal extension and the degree of tracheal compression correlate well with the presence and severity of tracheoesophageal pressure symptoms. None of the radiographic findings that are exclusive to substernal goitre (percentage of substernal mass, goitre size at the level of the thoracic inlet, ratio of goitre size to the vertebral body at the thoracic inlet and retrosternal isthmus size) had any correlation with clinical symptoms in this study.

Cannonball metastases with favourable prognosis.

BACKGROUND: Secondary 'cannonball' metastases to the lung are frequent and usually associated with disseminated malignancy and poor prognosis. AIM: To report the case of a patient with metastatic pulmonary endometrial stromal sarcoma who had a previous hysterectomy for benign uterine fibroids and no past history of malignancy. RESULT: A 70-year-old female presented with cannonball metastases in her lung. Four years previously she had a hysterectomy for 'fibroids'. Review of the original histology revealed endometrial stromal sarcoma, similar to the lung metastasis. She currently has a good prognosis. CONCLUSION: A patient with 'cannonball' metastases can have a favourable prognosis. A female patient with a previous hysterectomy for uterine fibroids, should be considered to have metastatic sarcoma until proven otherwise.

Venous covered stent: successful occlusion of a symptomatic internal iliac arteriovenous fistula.

We report the placement of a covered stent within the internal iliac vein (IIV) to occlude a symptomatic iatrogenic internal iliac arteriovenous fistula following an abdominal aortic graft. Angiography revealed a direct communication between an internal iliac graft to artery anastomosis and the right IIV with rapid shunting into the inferior vena cava and a small associated pseudoaneurysm. Femoral, brachial or axillary arterial access was precluded. The fistula was successfully occluded by a stent-graft placed in the IIV. Arteriovenous fistula can be treated in a number of ways including covered stent placement on the arterial side. To the best of our knowledge this is the first time placement in a vein has been described. Where access is difficult or the procedure carries a high risk of complication, a venous covered stent may offer an alternative.

Neurovascular compression of the trigeminal and glossopharyngeal nerve: three case reports.

Trigeminal neuralgia (TN) is a frequent cause of paroxysmal facial pain and headache in adults. Glossopharyngeal neuralgia (GPN) is less common, but can cause severe episodic pain in the ear and throat. Neurovascular compression of the appropriate cranial nerve as it leaves the brain stem is responsible for the symptoms in many patients, and neurosurgical decompression of the nerve is now a well accepted treatment in adults with both TN and GPN who fail to respond to drug therapy. Neither TN nor GPN are routinely considered in the differential diagnosis when assessing children with paroxysmal facial or head pain, as they are not reported to occur in childhood. Case reports of three children with documented neurovascular compression causing severe neuralgic pain and disability are presented. The fact that these conditions do occur in the paediatric population, albeit rarely, is highlighted, and appropriate investigation and management are discussed.

Pulmonary magnetic resonance angiography.

Early attempts to image the pulmonary vasculature with spin-echo magnetic resonance (MR) imaging were hampered by severe image degradation related to respiratory and cardiac pulsation artifact, susceptibility at interfaces between lung parenchyma and vessel wall, and poor contrast between flowing blood and intravascular filling defects of emboli. With the development of gradient-echo MR angiographic techniques some of these limitations were overcome; however, the need for multiple breath-holds and the frequent occurrence of flow-related artifacts that could simulate pulmonary emboli diminished their clinical utility. With the development of contrast-enhanced MR angiography, many of the limitations of earlier techniques were addressed. Images of both lungs with high signal-to-noise ratios and high contrast between flowing blood and pulmonary emboli could be acquired in a single breath-hold, during "first-pass" imaging with extracellular contrast agents in the coronal plane. However, subsegmental vessels could not be assessed with this approach. The technique has been refined further by imaging each lung separately in the sagittal plane; this offers higher resolution and total lung coverage and requires a shorter breath-hold. Finally, several investigators have reported preliminary data on imaging of the pulmonary vasculature with blood pool agents, exploiting respiratory triggering or navigator echoes to eliminate the need for breath-holding for the detection of pulmonary emboli.

Non-invasive evaluation of the visceral arteries with magnetic resonance angiography.

Traditionally, there have been only a few indications for imaging of the visceral arteries. With improvements in treatment of many mesenteric vascular disorders, it has become more important to establish a diagnosis early in the course of the disease. With the advent of ultrasound, computed tomography and magnetic resonance imaging non-invasive imaging of the visceral arteries became possible, although all these modalities were limited in scope for demonstration of mesenteric pathology. The advent of high-quality mesenteric MR arteriography and venography, which allows comprehensive evaluation of both visceral artery anatomy and function, has led to a huge increase in the number of studies directed at the mesenteric arteries in many departments.

Pulmonary MR angiography.

Imaging of the pulmonary vasculature with "inflow" MR imaging is difficult both to perform and interpret. Over the last few years, however, a greater understanding of contrast-enhanced techniques and the availability of fast gradient performance have facilitated the development of high resolution breath-hold images with high contrast-to-noise ratios. Increasing clinical experience with these contrast-enhanced techniques suggests a likely role for MR angiography in investigating patients with a variety of pulmonary vasculature disorders, including pulmonary embolism, pulmonary hypertension and arterio-venous malformation.