Clinicoradiological features of cerebral microbleeds diagnosed on magnetic resonance neuroimaging.

Objectives: Cerebral microbleeds (MBs) are recently described entity on magnetic resonance (MR) neuroimaging and are considered one of the markers of small vessel disease. We aimed to study the clinicoradiological features of cerebral MBs that were diagnosed in MR neuroimaging. Materials and Methods: We studied 109 South Indian patients, who presented to a tertiary care institution for MR neuroimaging with cerebral MBs as diagnosed on MR neuroimaging based on either the gradient T2* imaging or susceptibility-weighted imaging. The clinical details and coexisting MR features of infarcts, macrohemorrhages, lacunar infarcts, and white matter leukoaraiosis were evaluated and analyzed. Results: Of 109 patients, 79 were males and 30 were females. Associated clinical comorbidities noted include hypertension (62.39%), diabetes (23.85%), and alcoholism (31.19%) apart from the history of anti-platelet/anti-coagulant usage (15.5%), previous cardiac disease (12.84%), and previous stroke/transient ischemic attacks (9.17%). Other co-existing neuroimaging abnormalities noted include cortical infarcts (27.52%), old hemorrhages (29.36%), lacunar infarcts (56.88%), and white matter leukaraiosis (67.89%). Conclusion: The clinicoradiological features of cerebral MBs in South Indian patients are similar to other Asian and Western studies with significant coexistence of clinical comorbidities and imaging features of small vessel changes. Further studies with a larger sample are needed to correlate the grade of MBs to the individual risk of these clinicoradiological characteristics.

Comparison of airway collapsibility following single induction dose ketamine with propofol versus propofol sedation in children undergoing magnetic resonance imaging: A randomised controlled study.

Background and Aims: Adequate sedation is essential for children undergoing magnetic resonance imaging (MRI) console. Propofol is commonly used for sedation, but it has the drawback of upper airway collapse at higher doses, which may be overcome by ketamine. This study was designed to evaluate the beneficial effect of ketamine on propofol in preventing airway collapse. Methods: Fifty-eight children undergoing MRI were randomised to Group P (propofol bolus dose followed by infusion or Group KP (bolus dose of ketamine and propofol followed by propofol infusion). The primary aim is to compare the upper airway cross-sectional area (CSA) and diameters (transverse diameter [TD] and anteroposterior diameter [APD]) obtained from MRI during inspiration and expiration. Results: Upper airway collapse as measured by delta CSA in mean (SD) [95% confidence interval] was statistically more significant between the two groups [at the soft palate level, 16.9 mm2 (19.8) [9.3-24.4] versus 9.0 mm2 (5.50) [6.9-11.1] (P = 0.043); at the base of the tongue level, 15.4 mm2 (11.03) [11.2-19.6] versus 7.48 mm2 (4.83) [5.64-9.32] (P < 0.001); at the epiglottis level, 23.9 (26.05) [14.0-33.8] versus 10.9 mm2 (9.47) [7.35-14.5] (P = 0.014)]. A significant difference was obtained for TD at all levels and for APD at the soft palate and base of tongue level. Conclusion: Adding a single dose of ketamine to propofol reduced the upper airway collapse significantly, as evidenced by the MRI-based measurements of upper airway dimensions, compared to propofol alone.

Is optic nerve sheath diameter a promising screening tool to predict neurological outcomes and the need for secondary decompressive craniectomy in moderate to severe head injury patients? A prospective monocentric observational pilot study.

Background: Optic nerve sheath diameter (ONSD) has been shown to be a noninvasive and quick method to calculate intracranial pressure (ICP) and subsequent neurologic outcomes, although with variable cutoffs. ICP can be indirectly assessed by noninvasive methods such as transcranial Doppler, ONSD, tympanic membrane displacement, and fundoscopy. Knowledge regarding the diagnostic accuracy of ONSD for predicting unfavorable outcomes within 72 hours (h) of moderate and severe head injury is limited. The objective of this study was to measure ONSD measurements at 24-h intervals in moderate to severe head injury patients and to find its association with clinical outcomes in the target population. Methods: This prospective observational study was done on moderate to severe head injury patients. ONSD was measured twice at 24-h intervals over 48 h. The clinical outcome was divided into the favorable group (patients who were in conservative treatment with a stable Glasgow Coma Scale [GCS] score and discharged following treatment) and the unfavorable group (patients who had a drop in GCS motor score of one or more, or expired or underwent surgical intervention) within 72 h following traumatic brain injury. The Kruskal-Wallis test, Mann- Whitney test, and receiver operating characteristic curves were used to establish the association between ONSD and clinical outcomes. Results: ONSD values measured at 24-h intervals >6.1 mm (P < 0.0146) and 6.2 mm (P < 0.0001) were found to be predictors of unfavorable outcomes (expired or underwent surgery), and hence the need for a secondary decompressive craniectomy (DC). Conclusion: ONSD is an efficient screening tool to assess neurological outcomes in severe head injury patients. It can reliably predict the need for secondary DC at an earlier stage before secondary brain damage ensues in these patients.

Atretic cephaloceles with different imaging phenotypes - Case series with review of literature.

Atretic cephaloceles (ACs) are congenital skull defects with herniation of rudimentary intracranial structures through the defect and associated with persistent falcine sinus or embryonic positioning of straight sinus. We describe five cases of ACs, out of which only one had embryonic straight sinus. Three cases had other intracranial malformations such as hypoplasia of corpus callosum, dysplastic tectum in one child and parieto-occipital polymicrogyria with falcotentorial dehiscence in the other, and frontal horn deformity and cortical dysplasia in the third. The prognosis of AC depends on the coexistent intracranial abnormalities and this highlights the role of magnetic resonance imaging in diagnosing the other associated anomalies for prediction of prognosis and planning of necessary surgical management.

Socio-demographic factors, clinico-radiological profile of patients with traumatic cervical spine injury in South India, and its association with short-term clinical outcome.

Background: Spinal cord injury is a devastating condition to an individual and his/her family imposing an economic burden on the family, society, and the country. Finding out the demographic and morbidity profile of cervical spine injuries is essential for formulating means and ways for its prevention and treatment. Aim: This study aimed at assessing the clinico-radiological and socio-demographic profile of cervical spine injury patients and their association with short-term clinical outcomes. Methods: This was a prospective observational study that included 120 patients with cervical spine/cord injury. Social, demographic, clinical, and radiological parameters of the study participants were recorded. Improvement, worsening, and neurological stability at 2 weeks follow-ups were considered as a short-term outcome. The association of neurological outcomes with clinico-radiological profile and socio-demographic characteristics was analyzed to study the level of significance. Results: The study found that nearly 81% of the study participants were involved in heavy physical activity, and 45% of the cases sustained cervical spine injury because of falls from height. About 37% and 55% of patients had complete and incomplete cord injury, respectively. Computerized tomography of the spine injury patients showed a fracture, subluxation, and locked facets. Magnetic resonance imaging showed disco-ligamentous injury and cord contusion in these patients. Nearly 29% of patients showed motor improvement, and around 4% of patients had a worsening of their neurological status after 2 weeks. Conclusion: Most of the people who sustain cervical spine injuries are involved in heavy physical work. Female gender, incomplete cord injury, and unilateral locked facet in subluxation are associated with good neurological outcomes. This study will form a preliminary base to build a larger database on spinal cord injury at the regional and national levels.

Unusual Presentation of a Rib Osteochondroma as Hard Breast Lump in a Young Male: A Case Report.

Osteochondroma arising from the rib is rare. They arise as bony outgrowths from the rib and extend either extrathoracically into the subcutaneous plane or intrathoracically compressing the lung or mediastinal structures. A 23-year-old male patient presented with complaints of breast lump since last year. On clinical examination, a hard bony projection with lobulated contour was palpable. Chest radiograph and contrast-enhanced CT showed a bony outgrowth arising from the anterior aspect of costochondral junction of the right fourth rib with displacement of pectoralis major muscle anteriorly. Osteochondroma should be considered as a differential diagnosis in the presentation of hard lump in the breast along with other chest wall tumors.

Spectrum of intracranial and spinal epidermoids including unusual locations and imaging findings: A pictorial review.

Intracranial and spinal epidermoids are benign slow-growing congenital lesions. They are predominantly intradural, extra-axial in location, with intra-axial locations (intra-parenchymal and spinal intramedullary) being rare. The most common locations of intradural epidermoids are cerebellopontine angle cistern followed by supra- and para-sellar regions, and fourth ventricle. Less common locations include inter-hemispheric fissure, sylvian fissure, lateral ventricle, intracerebral, velum interpositum cistern, superior cerebellar cistern and pineal gland. They can also be extradural, usually arising in the diploic space of the calvaria, though they are less common. Magnetic resonance imaging is the primary modality for diagnosis and knowing the extent of the lesion. In this pictorial review, we intend to illustrate their classical and unusual locations, atypical imaging findings including calcifications, rare complications like haemorrhage or spontaneous rupture.

Clinicoradiological Profile of Incomplete Hippocampal Inversion Diagnosed on MR Neuroimaging.

Background and Purpose: Incomplete hippocampal inversion (IHI) is a developmental failure of normal hippocampal inversion. Previous studies have described IHI in epilepsy and non-epilepsy subjects. IHI has also been reported with malformations of cortical development (MCDs) and corpus callosal agenesis that have association with neuropsychiatric disorders such as autism spectrum disorder (ASD). This study aims to describe the clinical profile of magnetic resonance imaging (MRI)-diagnosed IHI. Materials and Methods: We studied patients with IHI who were identified after a retrospective review of the MRI archives of the past 3 years. The MRI findings of partial and total IHI were included. The clinical profiles associated with IHI were classified into epilepsy and non-epilepsy categories. Results: A retrospective review of MRI done over 3 years revealed 54 cases of IHI (32 left-sided, 20 bilateral, and 2 isolated right-sided), and out of 74 IHI, 59 were of total type and 15 partial. Thirty-six subjects (61.1%) had epilepsy (9 with neurodevelopmental problems), 17 subjects (31.5%) had ASD, and 4 subjects (7.4%) had only neurodevelopmental disorders. MCDs were seen in 7 (12.9%): polymicrogyria (4), periventricular heterotopia (2), and pachygyria (1). Hippocampal volume loss was seen in 10, and contralateral mesial temporal sclerosis was seen in 2 patients. Conclusion: Hippocampal inversion has been reported in MRI scans of patients with epilepsy, ASD, MCDs, and many other related disorders. Further studies are required to know its occurrence among patients who get MRI scans due to many other disorders such as headaches, psychiatric disorders, minor hear trauma, and perinatal insults. If possible, studies among normal populations also need to be done.

Effect of Zoledronic Acid in Hepatic Osteodystrophy: A Double-Blinded Placebo-Controlled Trial.

Purpose: Literature on the treatment of pre-transplant hepatic osteodystrophy (HOD) is limited. The general treatment measures and their timing are currently adopted from the literature on postmenopausal osteoporosis. Therefore, we conducted this randomized study to investigate the effect of zoledronic acid (ZA) on HOD. Methods: We randomized 36 male patients with cirrhosis (Child-Pugh class A and B) into 19 to the ZA arm and 17 to the placebo arm, respectively. Patients in the ZA arm received a single infusion of 4 mg ZA dissolved in 100 mL of normal saline at baseline, while patients in the placebo arm received a similar infusion of normal saline at baseline. The primary outcome of the study was the change in lumbar spine bone mineral density (LS-BMD) at 12 months. Results: Of 36 patients, 28 completed the study (15 in the ZA arm and 13 in the placebo arm). The mean increase in LS-BMD (g/cm2) in the ZA and placebo arms was 5.11% (3.50) and 0.72% (4.63) [P = 0.008], respectively. The trabecular bone score (TBS) did not improve significantly in either arm. The incidence of vertebral fractures (VFs) was similar in both arms. There was a significant decrease in plasma beta-C-terminal telopeptide (ß-CTX) levels in the ZA arm compared to the placebo arm, while the change in plasma levels of procollagen 1 intact N-terminal propeptide (P1NP) was similar in both arms. Six patients (31.6%) in the ZA arm experienced adverse reactions such as fever and myalgia. Conclusion: ZA improved LS-BMD in male patients with HOD by decreasing bone resorption. However, it may not improve trabecular microarchitecture or prevent morphometric VFs in this population.

Morphometric evaluation of great vein of Galen and its clinical implications / 대한해부학회지

The Galenic venous system plays a vital role in the drainage of blood from deeper parts of the brain. This venous system is contributed by many major veins. These veins are located closer to the pineal gland making the surgical approach in this region difficult. Any accidental injury or occlusion of the vein of Galen could lead to devasting results. Thus, studying the dimensions of the vein of Galen is more important. Hence, we aimed to evaluate the morphometry and trajectory to the vein of Galen. About 100 computed tomographic venography records were evaluated and the length, diameter of vein of Galen, angle between straight sinus and vein of Galen and distance from internal occipital protuberance and roof of fourth ventricle to vein of Galen were studied. The mean length and diameter of vein of Galen were 9.8±2.7 and 4.08±1.04 respectively. The mean angle between straight sinus and vein of Galen was 64.2°. The mean distance between external occipital protuberance and roof of fourth ventricle to vein of Galen were 52±6.9 and 33.3±4.5 respectively. No significant morphometric differences were observed between the age groups as well as between the sexs. The results obtained from this study may be helpful for the neurosurgeons in better understanding of the anatomy of the Galenic venous system and to adopt a safe surgical approach to improve the efficacy of the surgeries of the pineal gland and also in the region of vein of Galen.

Pituitary Dysfunction Following Snakebite Envenomation: A Clinico-Radiological Assessment of 15 Cases and Review of the Literature.

Background: Snakebite envenomation (SE) is an important tropical disease in India, causing significant morbidity and mortality among patients. The hormonal deficiencies due to the involvement of the pituitary in case of SE can present in either acute or delayed setting. Hypopituitarism (HP) is often an underrecognized and relatively rarely reported complication of this neglected disease. Methods: We present here the data of 15 patients diagnosed to have HP following systemic SE and are being currently followed-up in the Endocrinology outpatient department of a tertiary care hospital of South India. The study was approved by the Institute ethics committee, and informed onsent was taken from all the study patients. The study was a record-based retrospective analysis of the patients with HP following SE. Clinical data including lag time in diagnosis and type of snake were determined. Further, hormonal data including all the anterior pituitary functions (thyroid stimulating hormone, free T4, cortisol, insulin-like growth factor (IGF-1) luteinizing hormone, follicular-stimulating hormone, testosterone; prolactin) and water deprivation test to determine diabetes insipidus (DI) in patients with polyuria on follow-up were extracted from the records and the hospital information system. An experienced neuroradiologist examined the magnetic resonance imaging (MRI) findings of the pituitary. Results: The mean age of the patients was 43 ± 9 years and 80% were male. Around 90% of patients belonged to upper-lower socioeconomic status according to the modified Kuppuswamy scale. The commonest snake species reported was Russell's viper. Thirteen patients had delayed HP. The median duration from snakebite to onset of HP symptoms was 1 year (range 0.33-10 years). However, the median time from snakebite to the diagnosis of HP was 7 years (range 1-13 years). Central hypothyroidism and hypogonadism were present in all subjects. However, central hypocortisolism was noted in 93% of patients. Low IGF-1 was noted in all the six patients where data were available. One patient had partial central DI. Thirteen out of 15 patients had reduction of pituitary volume in MRI. Conclusion: HP in patients with SE can appear slowly and the diagnosis is frequently delayed for years. Following snakebite, multiple pituitary hormone deficiencies associated with radiological abnormalities like a significant reduction in the pituitary volume are common.

Corticospinal Tract Involvement in MRI of Neuromelioidosis: Report of Three Cases with a Review of Clinicoradiological Features.

Melioidosis is gram-negative bacterial infection endemic in parts of Australia and Asia with significant morbidity and mortality. It is acquired in wet rainy seasons through occupational and recreational activities. Although central nervous system (CNS) involvement is seen in less than 10%, it can have severe sequelae. MRI (magnetic resonance imaging) findings in reported cases have shown predominant brain stem and frontoparietal involvement. We present three pediatric cases of neuromelioidosis in which corticospinal tract involvement was a characteristic finding.

Susceptibility or chemical shift artifacts in intracranial lipomas mimicking hemorrhage - Case series with review of the literature.

Intracranial lipomas are rare congenital malformations which are present in choroid plexus or subarachnoid locations along the corpus callosum and cisterns. Most of them are identified incidentally during neuroimaging studies done for other indications. Sometimes, they may be associated with other anomalies such as agenesis of corpus callosum and vascular malformations. In magnetic resonance imaging (MRI), they may be associated with chemical shift artifact (CSA) due to their lipid content and can mimic other more serious intracranial lesions. This effect seen in gradient echo MRI sequences can also be used to confirm the presence of these lesions. We report the imaging findings of six patients with intracranial lipomas that showed this chemical shift artifact with a review of the literature.

Alkaline pH in intracranial tuberculomas: A 31Phosphorus magnetic resonance spectroscopy study.

Objectives: Intracranial tuberculomas are one of the common causes of space-occupying lesions of the brain in developing countries. Proton (1H) magnetic resonance spectroscopy (MRS) has shown lipid peak in intracranial tuberculomas as a characteristic feature. Phosphorus (31P) MRS has been used to evaluate intracranial lesions and to calculate tissue pH non-invasively. The aim of this study is to evaluate intracranial tuberculomas using 31PMRS. Materials and Methods: Intracranial tuberculomas proven by stereotactic or surgical biopsy were included in the study. After routine T1- and T2-weighted sequences, 31P MRS was performed using single-voxel intravoxel in vivo spectroscopy (ISIS) technique in the central core of the tuberculoma (voxel size 1-2 mm3). The pH was estimated using Petroff 's method using the chemical shift between phosphocreatine and Pi. Results: 31P MRS was available for 26 patients, in which there was significant positive correlation between high-energy phosphate metabolites, (markers of bioenergetic status), and low-energy phosphate metabolites (membrane phospholipids and inorganic phosphate). The calculated pH was slightly alkaline and varied from 6.97 to 7.22. Conclusion: Intracranial tuberculomas showed alkaline pH in 31P MRS and this may be useful in the characterization of these lesions and possibly also in their treatment.

CT Imaging in Predicting Ovarian Torsion: Report of Two Cases, With and Without Infarction.

Ovarian torsion is one of the common abdominal and gynecologic surgical emergencies with serious morbidity in the form of ovarian infarct or necrosis. Various imaging modalities like USG, CT, and MRI have been used in the evaluation of ovarian torsion. Two middle-aged females presented with lower abdominal pain. Imaging showed an ovarian cystic lesion in the first patient and thickened and twisted ovarian pedicle or 'helical swirling' sign in the second. Intraoperatively, the first case turned out to be a 180* twist with mild ovarian edema and the second showed more than 720* torsion with ovarian infarction. The CT findings of twisted pedicle with pericystic fat stranding might be predictive of hemorrhagic infarction in cases of torsion.

Thin-section 3D Steady-State MRI in Optic Nerve Coloboma.

Optic nerve colobomas are congenital defects in the posterior globe of eye with typical funduscopic appearances. We report a two-year-old child suspected of morning glory disc anomaly who underwent thin-section 3D steady-state magnetic resonance imaging which showed characteristic findings of a tiny defect and discontinuity in the optic nerve head.

A nomogram for predicting the risk of neck node metastasis in oral cavity carcinoma using acoustic radiation force impulse imaging (ARFI).

BACKGROUND: The study was conducted to assess the accuracy power of Acoustic radiation force impulse imaging (ARFI) and generate a nomogram using ultrasound and ARFI to predict malignant cervical lymph nodes in head and neck squamous cell carcinoma. MATERIAL AND METHODS: 374 cervical lymph nodes from 67 patients were evaluated. The B-mode ultrasonography and the elastography findings were compared with the final histopathological diagnosis. Radiological variables were used to construct nomogram and clinical utility of the nomogram was cross-validated. RESULTS: In univariate analysis, status of the hilum, Long Axis Diameter, Short axis diameter, colour virtual touch imaging grade (VTI) and shear wave velocity were significant in predicting metastasis in the cervical lymph nodes. In multivariable analysis, it was found that predominance of red over yellow area on colour VTI was significantly associated with lymph node metastasis. A multiple logistic regression performed to ascertain the effects of on the likelihood that patients had lymph node metastasis on histopathology was statistically significant, χ2(10) = 44.96, p < 0.001. The model was able to correctly classify 93.28% of cases and the concordance index (c-index) was estimated to be 0.8773. A nomogram was thus established to predict metastasis in cervical lymph nodes. CONCLUSIONS: ARFI increases the diagnostic accuracy of conventional USG in predicting metastatic lymph nodes in HNSCC. Adding the constructed nomogram to the conventional diagnostic pathway can provide an alternative option to frozen section and FNAC.