Clinical Results and Hematologic Predictors of Linear Accelerator-Based Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy for Brain Metastasis in Patients Aged 75 Years or Older: A Retrospective Study.

OBJECTIVE: This study aimed to evaluate prognostic factors including pre-radiosurgical blood count in elderly patients (EPs) with brain metastasis (BM) who were treated using linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator. METHODS: Between January 2011 and November 2021, 101 consecutive EPs with BM were treated by LINAC-based SRS or fSRT using LINAC with a micro-multileaf collimator. EPs were defined as patients aged ≥75 years. RESULTS: The tumors originated from the lungs (n = 90; 89.1%), colon (n = 2; 2.0%), and others (n = 9; 8.8%) in these EPs. The median pretreatment Karnofsky Performance Status was 80 (range, 40-100). The median follow-up time was 10 months (range, 0-76), as was the median survival. The 6-month, 1-year, and 2-year survival in the EP group was 58.3%, 43.2%, and 28.5%, respectively. Freedom from local failure at 6 months and 1 and 2 years was 97%, 95%, and 91.5%, respectively. Freedom from distant failure at 6 months and 1 and 2 years in EPs was 70.6%, 59.4%, and 54.2%, respectively. A high neutrophil/lymphocyte ratio >5.33 was an unfavorable predictor of prognosis for EPs with BMs treated with SRS and fSRT (P < 0.001). In the EPs, the prognostic factors associated with prolonged survival in the Cox proportional hazards model were being female and a good pretreatment Karnofsky Performance Status. CONCLUSIONS: The findings of our study highlight the efficacy of LINAC-based SRS and fSRT with a micro-multileaf collimator in the treatment of EPs with BMs. Neutrophil/lymphocyte ratio can be an important factor in treatment decisions for EPs with BMs.

Association of adverse childhood experiences and cortical neurite density alterations with posttraumatic stress disorder symptoms in autism spectrum disorder.

Background: Posttraumatic stress disorder (PTSD) can be a source of significant social and daily distress in autism spectrum disorder (ASD). Compared to typically developed (TD) individuals, people with ASD are at an increased risk of adverse childhood experiences (ACEs), which can result in abnormal neuronal development. However, whether or how ACEs influence abnormal neural development and PTSD symptoms in ASD has not been fully elucidated. Methods: Thirty-nine TD individuals and 41 individuals with ASD underwent T1-weighted magnetic resonance imaging and neurite orientation dispersion and density imaging (NODDI), with axonal and dendritic densities assessed in terms of the orientation dispersion index and neurite density index (NDI), respectively. Voxel-based analyses were performed to explore the brain regions associated with PTSD symptoms, and the relationships between the severity of ACEs and PTSD symptoms and NODDI parameters in the extracted brain regions were examined. Results: There was a significant positive association between PTSD symptom severity and NDI in the bilateral supplementary motor area; right superior frontal, left supramarginal, and right superior temporal gyrus; and right precuneus in the ASD group, but not in the TD group. ACE severity was significantly associated with NDI in the right superior frontal and left supramarginal gyrus and right precuneus in the ASD group. Moreover, NDI in the right precuneus mainly predicted the severity of PTSD symptoms in the ASD group, but not the TD group. Conclusion: These results suggest that ACE-associated higher neurite density is of clinical importance in the pathophysiology of PTSD symptoms in ASD.

Development of liposomal contrast agent with high iodine concentration and minimal effect on renal function.

Purpose: The use of contrast media is essential to achieve high accuracy in diagnostic imaging. Iodine contrast media, one of these contrast media, has nephrotoxicity as a side effect. Therefore, the development of iodine contrast media that can reduce nephrotoxicity is expected. Since liposomes are generally adjustable in size (100-300 nm) and are not filtered by the renal glomerulus, we hypothesized that iodine contrast media could be encapsulated in liposomes and administered to avoid the nephrotoxicity of iodine contrast media. The aim of this study is to develop an iomeprol-containing liposome (IPL) agent with high iodine concentration and to investigate the effect of intravenous administration of IPL on renal function in a rat model with chronic kidney injury. Materials and methods: IPLs were prepared by encapsulating an iomeprol (400mgI/mL) solution in liposomes by a kneading method using a rotation-revolution mixer. Radiodensities of iomeprol and IPL were measured. IPL or iopamidol at normal dose (0.74 g I/kg) or high dose (3.7 g I/kg) was administered to healthy and 5/6-nephrectomized rats (n = 3-6). Serum creatinine (sCr) and histopathological change of tubular epithelial cells were evaluated after injection. Results: The iodine concentration of IPL was 220.7 mgI/mL, equivalent to 55.2% of the iodine concentration of iomeprol. The CT values of IPL was 4731.6 ± 53.2 HU, 59.04% that of iomeprol. The ratios of change in sCr in 5/6-nephrectomized rats that received high-dose iopamidol were 0.73, which were significantly higher than that in 5/6-nephrectomized rats that received high-dose IPL (-0.03) (p = 0.006). Change in foamy degeneration of tubular epithelial cells was confirmed in 5/6-nephrectomized rats that received high-dose iopamidol than that in the sham control group and healthy rats that received normal dose iopamiron (p = 0.016, p = 0.032, respectively). Foamy degeneration of tubular epitherial cells was rarely observed in the IPL injection group. Conclusions: We developed new liposomal contrast agents that have high iodine concentration and minimal effect on renal function.

Long-Term Survival after Linac-Based Stereotactic Radiosurgery and Radiotherapy with a Micro-Multileaf Collimator for Brain Metastasis.

BACKGROUND: this study aimed to evaluate the prognostic factors associated with long-term survival after linear accelerator (linac)-based stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator for brain metastasis (BM). METHODS: This single-center retrospective study included 226 consecutive patients with BM who were treated with linac-based SRS or fSRT with a micro-multileaf collimator between January 2011 and December 2018. Long-term survival (LTS) was defined as survival for more than 2 years after SRS/fSRT. RESULTS: The tumors originated from the lung (n = 189, 83.6%), breast (n = 11, 4.9%), colon (n = 9, 4.0%), stomach (n = 4, 1.8%), kidney (n = 3, 1.3%), esophagus (n = 3, 1.3%), and other regions (n = 7, 3.1%). The median pretreatment Karnofsky performance scale (KPS) score was 90 (range: 40-100). The median follow-up time was 13 (range: 0-120) months. Out of the 226 patients, 72 (31.8%) were categorized in the LTS group. The median survival time was 43 months and 13 months in the LTS group and in the entire cohort, respectively. The 3-year, 4-year, and 5-year survival rate in the LTS group was 59.1%, 49.6%, and 40.7%, respectively. Multivariate regression logistic analysis showed that female sex, a pre-treatment KPS score ≥ 80, and the absence of extracranial metastasis were associated with long-term survival. CONCLUSIONS: female sex, a favorable pre-treatment KPS score, and the absence of extracranial metastasis were associated with long-term survival in the current cohort of patients with BM.

Linac-based stereotactic radiosurgery and fractionated stereotactic radiotherapy with a micro-multileaf collimator for brain metastasis in the primary motor cortex.

This study aimed to assess the clinical outcomes of linear accelerators (linac)-based, stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) with a micro-multileaf collimator for brain metastasis in the primary motor cortex (BMPMC). Thirty-five consecutive patients with BMPMC who were treated by linac-based SRS or fSRT between January 2012 and March 2020 were analyzed. BMPMC was defined as a tumor located in the precentral gyrus on gadolinium-enhanced magnetic resonance imaging (MRI) and T2-weghted imaging (T2WI). In total, 35 patients with 37 metastases were analyzed. The median follow-up time was 13 (range: 1-97) months. The tumor volume was 0.05-26.5 (median: 0.62) cm3. All patients were treated with SRS or fSRT using 35 Gy with 7 Gy per fraction daily. The median survival time (MST) was 16.9 months. The pretreatment KPS and RPA class significantly differed in terms of MST on the log-rank tests. Seven symptomatic patients had hemiparesis before SRS or fSRT. All symptomatic patients, except one with facial paresis and one who died within 3 months, experienced improvement at a 3 month follow-up. None of the patients presented with persistent radiation injury at the final follow-up. Two patients presented with grade 3 radiation-related central nervous system necrosis, which was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. In BMPMC, SRS and fSRT had good tumor control and did not cause serious complications. Therefore, they are suitable treatment options with an acceptable safety profile.

Salvage Surgical Resection after Linac-Based Stereotactic Radiosurgery for Newly Diagnosed Brain Metastasis.

BACKGROUND: This study aimed to assess the clinical outcomes of salvage surgical resection (SSR) after stereotactic radiosurgery and fractionated stereotactic radiotherapy (SRS/fSRT) for newly diagnosed brain metastasis. METHODS: Between November 2009 and May 2020, 318 consecutive patients with 1114 brain metastases were treated with SRS/fSRT for newly diagnosed brain metastasis at our hospital. During this study period, 21 of 318 patients (6.6%) and 21 of 1114 brain metastases (1.9%) went on to receive SSR after SRS/fSRT. Three patients underwent multiple surgical resections. Twenty-one consecutive patients underwent twenty-four SSRs. RESULTS: The median time from initial SRS/fSRT to SSR was 14 months (range: 2-96 months). The median follow-up after SSR was 17 months (range: 2-78 months). The range of tumor volume at initial SRS/fSRT was 0.12-21.46 cm3 (median: 1.02 cm3). Histopathological diagnosis after SSR was recurrence in 15 cases, and radiation necrosis (RN) or cyst formation in 6 cases. The time from SRS/fSRT to SSR was shorter in the recurrence than in the RNs and cyst formation, but these differences did not reach statistical significance (p = 0.067). The median survival time from SSR and from initial SRS/fSRT was 17 and 74 months, respectively. The cases with recurrence had a shorter survival time from initial SRS/fSRT than those without recurrence (p = 0.061). CONCLUSIONS: The patients treated with SRS/fSRT for brain metastasis need long-term follow-up. SSR is a safe and effective treatment for the recurrence, RN, and cyst formation after SRS/fSRT for brain metastasis.

Structures Showing Negative Correlations of Signal Intensity with Postnatal Age on T1-weighted Imaging of the Brain of Newborns and Infants.

PURPOSE: Although the neonatal and infantile brain typically shows sequential T1 shortening according to gestational age as a result of myelination, several structures do not follow this rule. We evaluated the relationship between the signal intensity of various structures in the neonatal and infantile brain on T1-weighted imaging (T1WI) and either postnatal or gestational age. MATERIALS AND METHODS: We examined magnetic resonance images from 120 newborns and infants without any abnormalities in the central nervous system. Written informed consent was obtained from all parents and the institutional review board approved the study. Gestational age at examination ranged from 35 weeks, 3 days to 46 weeks, 6 days, and postnatal age ranged from 7 days to 127 days. Signal intensity on T1WI was evaluated on a scale from Grade 1 (indistinguishable from surrounding structures) to Grade 4 (higher than cortex and close to fat). We evaluated relationships between the T1 signal grades of various structures in the neonatal brain and postnatal or gestational age using Spearman's correlation analysis. RESULTS: Significant positive correlations were identified between T1 signal grade and gestational age in the pyramidal tract (P < 0.001). Conversely, significant negative correlations were evident between T1 signal grade and postnatal age (P < 0.001), in structures including the stria medullaris thalami, fornix cerebellar vermis, dentate nucleus and anterior pituitary gland. CONCLUSION: Significant negative correlations exist between signal intensity on T1WI and postnatal age in some structures of the neonatal and infantile brain. Some mechanisms other than myelination might play roles in the course of signal appearance.

Application of histogram analysis for the evaluation of vascular permeability in glioma by the K2 parameter obtained with the dynamic susceptibility contrast method: Comparisons with Ktrans obtained with the dynamic contrast enhance method and cerebral blood volume.

PURPOSE: The "K2" value is a factor that represents the vascular permeability of tumors and can be calculated from datasets obtained with the dynamic susceptibility contrast (DSC) method. The purpose of the current study was to correlate K2 with Ktrans, which is a well-established permeability parameter obtained with the dynamic contrast enhance (DCE) method, and determine the usefulness of K2 for glioma grading with histogram analysis. METHODS: The subjects were 22 glioma patients (Grade II: 5, III: 6, IV: 11) who underwent DSC studies, including eight patients in which both DSC and DCE studies were performed on separate days within 10days. We performed histogram analysis of regions of interest of the tumors and acquired 20th percentile values for leakage-corrected cerebral blood volume (rCBV20%ile), K2 (K220%ile), and for patients who underwent a DCE study, Ktrans (Ktrans20%ile). We evaluated the correlation between K220%ile and Ktrans20%ile and the statistical difference between rCBV20%ile and K220%ile. RESULTS: We found a statistically significant correlation between K220%ile and Ktrans20%ile (r=0.717, p<0.05). rCBV20%ile showed a significant difference between Grades II and III and between Grades II and IV, whereas K220%ile showed a statistically significant (p<0.05) difference between Grades II and IV and between Grades III and IV. CONCLUSIONS: The K2 value calculated from the DSC dataset, which can be obtained with a short acquisition time, showed a correlation with Ktrans obtained with the DCE method and may be useful for glioma grading when analyzed with histogram analysis.

Dural Thickening of the Internal Auditory Canal in Patients With Spontaneous Intracranial Hypotension Syndrome.

OBJECTIVE: This study aimed to assess the utility of dural thickening of the internal auditory canal (IAC) in patients with spontaneous intracranial hypotension (SIH) syndrome and determined the sensitivity and specificity of this image finding. METHODS: Magnetic resonance images were evaluated for 22 cases of definite SIH and 16 cases of unlikely SIH. On contrast-enhanced magnetic resonance imaging, pachymeningeal enhancement and dural thickening of the IAC were assessed. RESULTS: Pachymeningeal enhancement was observed in 21 of 22 patients in the definite SIH group and 1 of 16 patients in the unlikely SIH group (sensitivity, 95.5%; specificity, 93.8%). Dural thickening of the IAC was observed in 15 of 22 patients in the definite SIH group and 0 of 16 patients in the unlikely SIH group (sensitivity, 68.2%; specificity, 100%). CONCLUSIONS: Dural thickening of the IAC showed 100% specificity for SIH syndrome and can increase the accuracy of diagnosis of SIH syndrome.

"Cerebellar peduncle quarter notes" formed by the superior and middle cerebellar peduncles: comparison with a diffusion tensor study of spinocerebellar degeneration.

PURPOSE: To investigate morphological changes of the superior and middle cerebellar peduncles (SCP, MCP) in spinocerebellar degeneration (SCD) by observing "cerebellar peduncle quarter notes". MATERIALS AND METHODS: We examined 21 patients with SCD, including nine patients with multiple system atrophy cerebellar type (MSA-C), and 24 controls. We measured SCP angle and performed diffusion tensor analysis to quantify the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) of the MCP. We quantified the relationship between SCP angle and the ADC and FA of the MCP, and compared these variables between MSA-C patients and controls. RESULTS: There was statistically significant negative correlation between SCP angle and FA of the MCP, and a positive correlation between SCP angle and the ADC of the MCP. Mean SCP angle was larger among MSA-C patients than among normal controls. CONCLUSIONS: SCP angle tended to be larger among patients with severe degeneration of the MCP. The SCP angle, quantified by observing "cerebellar peduncle quarter notes", may be a simple index for evaluation of degeneration of the MCP.

Comparison between two separate injections and a single injection of double-dose contrast medium for contrast-enhanced MR imaging of metastatic brain tumors.

PURPOSE: As stereotactic radiotherapy (SRT) becomes widespread, precise information including number, location, and margin of lesions is required when magnetic resonance (MR) imaging of brain metastasis is performed. We compare methods using 2 separate injections and a single injection for the administration of a double dose of contrast medium for contrastenhanced MR imaging. MATERIALS AND METHODS: We divided 40 patients with brain metastasis into 2 groups of 20 patients. Group A received 2 separate injections (0.2 + 0.2 mL/kg) of contrast medium (gadoteridol); Group B received a single injection of the same total dose (0.4 mL/kg). Group A underwent spin echo (SE) T1-weighted imaging (T1WI) and magnetization prepared rapid acquisition with gradient echo sequence (MPRAGE) after each injection, and Group B underwent the same MR studies at the same timing as Group A. We evaluated the number, signal-to-noise ratio (SNR), diameter, margin delineation, and volume of lesions and compared them between early and delayed studies by the 2 methods. RESULTS: The number of detected lesions was largest in delayed studies of MPRAGE in both groups. The SNR of the lesions was statistically lower in early studies of Group A than other studies. Delayed studies of Group B showed statistically better margin delineation than other studies on both SE-T1WI and MPRAGE studies. Diameter and enhanced volume were statistically significantly larger on delayed phase than early phase in both groups. CONCLUSION: Use of a single injection of double-dose contrast medium and longer delay time may improve margin delineation of lesions for the study of brain metastasis. Enhanced volume was larger on delayed phase, and it may influence selection of therapeutic strategy.

Simple technique for gasless transumbilical single-incisional laparoscopic-assisted appendectomy.

PURPOSE: Single-incision laparoscopic surgery has recently received more attention. We developed a novel simple technique of gasless transumbilical single-incisional laparoscopic-assisted appendectomy (TUSILAA) and retrospectively analyzed our initial experience. METHODS: TUSILAA has been attempted in 50 consecutive patients with acute appendicitis. The vertical incision through the umbilicus was used for laparoscopic access and the abdominal wall was lifted by a Kent retractor set system. RESULTS: Our technique was successful in 45 out of 50 (90 %) patients. The median operating time was 59 min (range 35-140). The median length of postoperative hospital stay was 4 days (range 2-12). None of the cases were converted to open appendectomy. There were no perioperative surgical complications. CONCLUSIONS: Our novel technique, gasless TUSILAA, is safe and feasible with acceptable operative time and excellent cosmetic result. Furthermore, this procedure has the advantage of cost-effectiveness since any disposable instruments including trocars, staplers, or expensive devices are not required. Therefore, this could be used as the first-choice surgical procedure for selected patients with uncomplicated acute appendicitis.

Safety and feasibility for single-incision laparoscopic cholecystectomy in local community hospital: a retrospective comparison with conventional 4-port laparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to evaluate the safety and feasibility for single-incision laparoscopic cholecystectomy (SILC) by retrospective comparison with conventional laparoscopic cholecystectomy (CLC) in a local community hospital. METHODS: SILC was introduced and performed in 57 patients for benign gallbladder diseases. Their clinical data were compared with those of 62 patients treated with CLC. They included patient demographic data and operative outcomes. RESULTS: SILC was attempted in 57 patients and 52 cases (91.2%) were successfully completed. There were no statistical differences between the 2 groups in terms of operative time, blood loss, and postoperative complications. The length of hospital stay in the SILC group was significantly shorter compared with CLC (P < 0.0001). CONCLUSIONS: SILC has been successfully introduced in a local community hospital. The safety and feasibility was also confirmed. The SILC procedure may become 1 standard option for the treatment of benign gallbladder diseases.

Accuracy for predicting adhesion between meningioma and the brain by using brain surface motion imaging: comparison between single and double acquisition methods.

INTRODUCTION: The presence of adhesions between the brain and the meningioma is an important factor that determines the success of total surgical removal. Brain surface motion imaging enables assessment of the dynamics of brain surface motion. A subtraction image of pulse-gated heavily T2-weighted images in different phases of the cardiac cycle provides a stripe pattern on the surface of the pulsating brain. Thus, the lack of a stripe pattern on the surface of extraaxial tumor indicates the presence of tumor-brain adhesion. The purpose of the present experiment was to evaluate the accuracy of predicting tumor-brain adhesion using the original double acquisition method and the improved single acquisition method. METHODS: The subjects were 67 meningioma cases patients who were surgically treated after brain surface motion imaging. Thirty-three cases were evaluated using the double acquisition method and 34 cases were evaluated with the single acquisition method. In the double acquisition method, the two sets of images are acquired as two independent scans, and in the single acquisition method, the images are acquired serially as a single scan. RESULTS: The findings for the double acquisition method agreed with the surgical findings in 23 cases (69.7 %), while findings from the single acquisition method agreed with the surgical findings in 26 cases (76.5 %). CONCLUSION: Pre-surgical evaluation for tumor-brain adhesion by brain surface motion imaging provides helpful information for meningioma surgery, especially when using the single acquisition method.

Application of susceptibility weighted imaging (SWI) for evaluation of draining veins of arteriovenous malformation: utility of magnitude images.

INTRODUCTION: The current study evaluated the signal characteristics of susceptibility weighted imaging (SWI) of arteriovenous malformation (AVM), especially for draining veins. For this purpose, we identified the draining veins of the AVM on angiography and evaluated the signal on magnitude image for SWI (SWI-mag) and minimum intensity projection image (SWI-minIP). METHODS: Subjects were 14 cases with angiographically proven AVM. SWI-mag, SWI-minIP, and time-of-flight (TOF) magnetic resonance angiography were acquired. For the draining veins of the AVM identified on angiography, we analyzed signal intensity on the images listed above, and classified it into hyperintensity (hyper), mixed intensity (mixed), hypointensity (hypo), and no visualization. RESULTS: On the analysis of 27 angiographically proven draining veins, 19 draining veins were classified as hyper, 3 as mixed, 0 as hypo, and 6 as no visualization on SWI-mag. On TOF images, 21 draining veins were classified as hyper, 2 as mixed, 0 as hypo, and 4 as no visualization, while 6 draining veins did not show hyperintensity on TOF, and SWI-mag visualized 3 of these 6 veins as hyper. CONCLUSION: SWI-mag depicted most draining veins of AVM as hyperintensity. We speculate that this is mainly due to the higher concentration of oxygenated hemoglobin (oxy-Hb) and inflow effect of the draining vein. SWI-mag seems to be useful in the analysis and follow-up for AVM as the signal on the image may reflect physiological status.

Branching pattern of lenticulostriate arteries observed by MR angiography at 3.0 T.

PURPOSE: We hypothesized that the pattern of branching of the lenticulostriate arteries (LSAs) is involved in the variation of the distribution of the infarction within the LSA region. Our purpose was to evaluate the visibility of LSAs in 3D time-of-flight (TOF) MR angiography (MRA) with a 3.0 T scanner and to investigate the branching patterns of LSAs. MATERIALS AND METHODS: We performed 3D TOF MRA at 3.0 T for 100 healthy subjects. We assessed the number of LSAs and the number of branches arising from each LSA by evaluating MRA source images. RESULTS: In 200 hemispheres, 330 LSAs were visualized (mean = 1.65/hemisphere). In 3.5% of all hemispheres, no LSA was depicted; one LSA was depicted in 39%, two in 46.5%, and three in 11%. The maximum number of depicted LSA branches was five in 2% of all subjects, four in 7%, three in 26%, and two in 49% (mean = 2.3/subject). A large LSA trunk with three or more branches was found in 35% of subjects. CONCLUSION: Visualization of LSAs was possible in 96.5% of subjects by use of 3.0 T MRA. LSA branching patterns were variable, and a large LSA trunk with three or more branches was common.

Diffuse vascular injury: convergent-type hemorrhage in the supratentorial white matter on susceptibility-weighted image in cases of severe traumatic brain damage.

INTRODUCTION: Susceptibility-weighted image (SWI) is one of the most sensitive methods for detect microbleeding and useful for evaluation of traumatic brain damage. The purpose of this study is to delineate the characteristics and importance of supratentorial deep white matter hemorrhages detected by SWI in cases of traumatic brain damage. METHODS: Twenty-one consecutive cases with severe traumatic head injury were included in the current study. MRI examinations were made within 1 month after injury. We evaluated the degree and distribution of the supratentorial hemorrhages on SWI retrospectively. We classified the degree of bleeding into four grades: "small hemorrhage," "single bead-like hemorrhage," "convergent-type hemorrhage," and "massive hemorrhage." We then correlated the degree and distribution of the hemorrhage to clinical outcomes. We also evaluated the apparent diffusion coefficient (ADC) image of lobes with "convergent-type hemorrhage." RESULTS: Existence of "massive hemorrhage" correlated with a poor outcome, that is, worse than "severely disabled" on the Glasgow Outcome Scale. The number of lobes affected by "convergent-type hemorrhage" also correlated with poor outcome. There were 45 lobes with "convergent-type hemorrhage" and 27 of them showed increased diffusivity on ADC images. CONCLUSION: Supratentorial massive hemorrhages and supratentorial convergent-type multiple hemorrhages were associated with poor prognosis after traumatic brain injury. The increased diffusivity in lobes with convergent-type hemorrhages may indicate that congestion of the proximal medullary vein may play some role for these hemorrhages.

Discrepancy in T1 and T2 shortening of the globus pallidus in hepatic insufficiency: evaluation by susceptibility-weighted imaging.

PURPOSE: We assessed the signal of the globus pallidus (GP) in cases of hepatic insufficiency, especially to evaluate the degree of discrepancy in paramagnetic effects on shortening of T(1) and T(2)* using susceptibility-weighted images (SWI). MATERIALS AND METHODS: Seven patients with hepatic insufficiency underwent magnetic resonance (MR) examinations that included T(1)-weighted images (T(1)WI), T(2)-weighted images (T(2)WI), and SWI on a 1.5-tesla MR imager, and we compared their results to those of controls. On T(1)WI and T(2)WI, we measured signal intensity in the GP and posterior segment of the putamen (Put) to obtain a signal ratio (GP/Put ratio), and on SWI, we classified signal intensity into 4 grades: A, higher than the cortex; B, lower than the cortex and higher than the cerebrospinal fluid (CSF); C, lower than the CSF and higher than the red nucleus; and D, lower than the red nucleus. RESULTS: In the 7 patients with hepatic insufficiency, the mean GP/Put ratio was significantly higher on T(1)WI and T(2)WI than those values in controls. On SWI, we classified 2 cases each as Grade A, Grade B, and Grade C, and one as Grade D. Although the signal of the GP was elevated on T(1)WI, there was no decrease in signal on T(2)WI. On SWI, we obtained no low signal intensity. CONCLUSION: In patients with hepatic insufficiency, the globus pallidus did not show low signal intensity on either T(2)WI or SWI. Hyperintensity of the GP on T(1)WI without hypointensity on T(2)WI, or even SWI, suggests a discrepancy between paramagnetic effect on T(1) and T(2) shortening that reflects the accumulation of manganese and the presence of hepatic insufficiency.

Paeonianins A-E, new dimeric and monomeric ellagitannins from the fruits of Paeonia lactiflora.

Four new dimeric ellagitannins, paeonianins A-D (2-5), were isolated from the fruits of Paeonia lactiflora, together with a new ellagitannin monomer, paeonianin E (1). Their structures were determined by spectroscopic methods. Paeonianins A-D (2-5) are positional isomers formed by condensation of pentagalloyl-beta-D-glucose (8) with 5-desgalloylstachyurin (6) or casuariin (7). Paeonianin E is a C-glycosidic ellagitannin having a gallic acid methyl ester moiety at the glucose C-1 position. This is the first report of the isolation of dimeric ellagitannins from a plant in the family Paeoniaceae.