Anti-N-methyl-D-aspartate receptor encephalitis presenting as atypical psychosis in multiple sclerosis: a case report.

BACKGROUND: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune disorder which often presents with neuropsychiatric symptoms. A large proportion of cases are associated with an identifiable tumor, most commonly ovarian teratoma. However, recent literature has also described an overlap of anti-NMDAR encephalitis and demyelinating syndromes. Cases have been reported of anti-NMDAR encephalitis in patients with ADEM, optic neuritis, myelitis and multiple sclerosis. This link is considered rare, however has important clinical implications as treatments and prognosis may differ. CASE PRESENTATION: A 33-year-old female with a history of multiple sclerosis presented with new-onset neuropsychiatric symptoms. After substance-induced psychosis was ruled out, she was admitted to the medical ward for work up of psychosis secondary to multiple sclerosis. However, the consultation-liaison psychiatry service noted atypical symptoms which were concerning for autoimmune encephalitis. Admission to a psychiatric inpatient ward was deferred. Anti-NMDAR encephalitis was diagnosed with CSF analysis demonstrating lymphocytic pleocytosis and anti-NMDAR antibodies. In addition to first-line treatment of encephalitis with steroids, second-line immunotherapies were also implemented given the patient's underlining demyelinating syndrome. The patient's neurologic and psychiatric symptoms began to improve. CONCLUSIONS: There is literature to demonstrate a possible connection between anti-NMDAR encephalitis and demyelinating syndromes. As such, autoimmune encephalitis should be considered in patients with multiple sclerosis presenting with atypical symptoms. Determining the correct diagnosis is crucial to inform the appropriate treatment protocol, and to improve prognosis.

Standard B presentation vs. contrast-enhanced ultrasound (US-CE). A comparison of usefulness of different ultrasonographic techniques in the evaluation of the echo structure and size of haematomas inpost-renal transplant patients: A preliminary report.

BACKGROUND: During routine ultrasonographic examination in B presentation, performed as a standard diagnostic procedure during the early post-operative period, the most important problem with the interpretation of the images of perirenal haematoma is their ability to change in time. The aim of this work was to assess the echogenicity and the size of perirenal haematomas in patients after kidney transplant during routine examinations in B presentation and during examinations enhanced with a contrast medium (CE-US). MATERIAL/METHODS: Thirty-seven patients after kidney transplant were examined using standard examination in B presentation. Sixteen patients (7 women and 9 men) with isoechogenic and hypoechogenic areas visualized within the renal parenchyma, who were suspected of perirenal haematoma, underwent a CE-US examination after intravenous administration of sculpture hexafluoride (dose: 2.4 ml/examination). Using time-intensity curves (TIC), changes in the values were analysed for two areas of interest (ROI): in the renal parenchyma and in the areas identified during standard US as haematomas. Identical examination protocols and dynamic data loops allowed the acquisition of identical kidney cross-sections and enabled measuring the echogenicity and thickness of the abnormalities at the same location. RESULTS: During the routine B presentation examination, the average difference between haematoma and the renal cortex was 5 dB. When performing US-CE examination, a significantly greater difference in echogenicity was observed and reached 31 dB. In six patients, the size of haematomas was comparable using both techniques, whereas in ten patients lesions visualized in B presentation were smaller than in the US-CE examination. CONCLUSIONS: The US-CE examination demonstrated a greater, statistically significant, difference in the echogenicity of perirenal haematomas compared to the routine examination in B presentation. This method enabled a more detailed assessment of the size of haematomas in the perirenal space that appeared during early post-operative period.

Dynamic T1 functional MRI examinations with use of blood pool contrast agent--an approach to optimization of the technique.

The goal was to optimize dynamic T1 imaging for functional MRI (fMRI) examinations. For each of the 10 healthy subjects T1 3D gradient echo sequence (GRE) sequences were provided immediately after administration of blood pool contrast agent then every 2 h when subjects performed block finger tapings. Dynamic T1 fMRI is sensitive to detect cortical activations up to 6 h after BPCA administration. fMRI should be conducted within 2 h of CA administration, which is enough time for a typical fMRI experiment procedure.

Perfusion of kidney graft pyramids and cortex in contrast-enhanced ultrasonography in the determination of the cause of delayed graft function.

BACKGROUND: The aim of this study was to assess the usefulness of a new ultrasound technique - contrast-enhanced ultrasound examination (US-CE) - using sulphur hexafluoride in the early post-transplant assessment of graft perfusion. Time-intensity curves (TIC) were compared with hemodynamic flow parameters (resistive index: RI) in patients with good early graft function (EGF) and acute rejection (AR) or acute tubular necrosis (ATN) as a cause of delayed graft function (DGF). MATERIAL/METHODS: US-CE was conducted in order to assess graft perfusion in the early period after kidney transplantation (72-120 hours) in 63 kidney allograft recipients: 35 with EGF and 28 with DGF. The DGF patients were later diagnosed based on graft biopsy as AR (n = 10) or ATN (n = 18). Time-intensity curves were compared with hemodynamic flow parameters typically assessed in post-operative graft diagnostics (e.g., RI). RESULTS: In the examination with US-CE in EGF patients, the regular inflow of contrast medium was demonstrated in all regions of the graft. In patients with DGF, a delay in the inflow of the contrast medium was observed, as well as significant differences in the time of inflow to the regions of interest between those 2 groups. There was a significantly longer inflow time of the contrast medium to the cortex and renal pyramids in patients with AR than in ATN recipients. CONCLUSIONS: US-CE may be a valuable diagnostic tool in the determination of the cause of DGF.

A blood pool contrast aided T1 functional MRI in patients with brain tumors--a preliminary study.

INTRODUCTION: The aim of our study was to determine the possibility of using a new functional technique: a T1-dependent sequence with administration of blood pool contrast agent (BPCA), in patients with brain tumors before and after surgical treatment. We also aimed to compare our results with those obtained using the fMRI technique, based on Blood Oxygenation Level-Dependent (BOLD) contrast. METHODS: For each of our 14 oncologic patients (four before and ten after neurosurgical intervention), we obtained: a T1-3D GRE sequence (TR = 2.6 ms/TE = 1.1 ms/FA = 10°) after intravenous administration of BPCA (0.03 mmol/kg), as well as a T2*EPI sequence (TR = 3 s/TE = 50 ms/FA = 90°). Movement and/or tactile block type paradigms were carried out during both functional runs. SPM5 software was used for analysis. RESULTS: For both functional techniques, maximum activations were localized in the same areas. There were no significant differences observed in the t values calculated for activations located in the primary motor cortex between groups of pre- and post-intervention patients (in the same functional technique). The mean values for T2* EPI examinations were 10.84 and 9.36, respectively. The mean t values for the T1 technique were lower, especially for the post-intervention patients (5.83 and 3.9, respectively). CONCLUSIONS: The T1 technique can be used to detect functional areas in patients with brain tumors, pre-, and post-surgical intervention. This technique enables the evaluation of cortical centers that suffer from susceptibility artifacts when using the T2* BOLD technique. Activations found using both techniques have the same localization, with lower values for the T1 technique.

A large posttraumatic subclavian artery aneurysm complicated by artery occlusion and arteriobronchial fistula successfully treated using a covered stent.

The treatment of posttraumatic aneurysms of peripheral arteries using covered stents is increasingly commonplace. We present the case of a 10-year-old girl with a pseudoaneurysm of the subclavian artery complicated by an arteriobronchial fistula with hemorrhaging into the bronchial tree and distal subclavian artery occlusion. Despite the lack of artery patency, endovascular stent graft implantation was successful. Pseudoaneurysm exclusion and involution was achieved, together with a patent implant and maintained collateral circulation patency.