MRI and Blood-based Biomarkers Are Associated With Surgery in Children and Adults With Ileal Crohn's Disease.

BACKGROUND: Despite advances in medical therapy, many children and adults with ileal Crohn's disease (CD) progress to fibrostenosis requiring surgery. We aimed to identify MRI and circulating biomarkers associated with the need for surgical management. METHODS: This prospective, multicenter study included pediatric and adult CD cases undergoing ileal resection and CD controls receiving medical therapy. Noncontrast research MRI examinations measured bowel wall 3-dimensional magnetization transfer ratio normalized to skeletal muscle (normalized 3D MTR), modified Look-Locker inversion recovery (MOLLI) T1 relaxation, intravoxel incoherent motion (IVIM) diffusion-weighted imaging metrics, and the simplified magnetic resonance index of activity (sMaRIA). Circulating biomarkers were measured on the same day as the research MRI and included CD64, extracellular matrix protein 1 (ECM1), and granulocyte-macrophage colony-stimulating factor (GM-CSF) autoantibodies (Ab). Associations between MRI and circulating biomarkers and need for ileal resection were tested using univariate and multivariable LASSO regression. RESULTS: Our study sample included 50 patients with CD undergoing ileal resection and 83 patients with CD receiving medical therapy; mean participant age was 23.9 ±â€…13.1 years. Disease duration and treatment exposures did not vary between the groups. Univariate biomarker associations with ileal resection included log GM-CSF Ab (odds ratio [OR], 2.87; P = .0009), normalized 3D MTR (OR, 1.05; P = .002), log MOLLI T1 (OR, 0.01; P = .02), log IVIM perfusion fraction (f; OR, 0.38; P = .04), and IVIM apparent diffusion coefficient (ADC; OR, 0.3; P = .001). The multivariable model for surgery based upon corrected Akaike information criterion included age (OR, 1.03; P = .29), BMI (OR, 0.91; P = .09), log GM-CSF Ab (OR, 3.37; P = .01), normalized 3D MTR (OR, 1.07; P = .007), sMaRIA (OR, 1.14; P = .61), luminal narrowing (OR, 10.19; P = .003), log C-reactive protein (normalized; OR, 2.75; P = .10), and hematocrit (OR, 0.90; P = .13). CONCLUSION: After accounting for clinical and MRI measures of severity, normalized 3D MTR and GM-CSF Ab are associated with the need for surgery in ileal CD.

Despite advances in medical therapy, many patients with ileal Crohn's disease progress to fibrostenosis requiring surgery. Our study has shown that GM-CSF autoantibodies and MRI biomarker sequences are associated with the need for ileal resection and may help guide management decisions.

Imaging and clinical predictors of surgery in stricturing ileal Crohn's disease: a retrospective study from a large pediatric hospital.

PURPOSE: (1) To determine the frequency of surgical management in children with Crohn's Disease (CD) and a new radiologic ileal stricture, and (2) to identify imaging and clinical features that predict the need for surgery. METHODS: This retrospective study included pediatric patients (< 21 years old) with CD and a new ileal stricture diagnosed by MRE, CTE, or CT between July 2018 and June 2023. Three board-certified radiologists recorded stricture length, maximum mural thickness, minimum lumen diameter, maximum upstream diameter, and simplified magnetic resonance index of activity (sMaRIA) score. Anthropometrics, laboratory data, and surgical interventions performed after stricture diagnosis were also recorded. Multivariable logistic regression was used to identify imaging and clinical variables associated with the need for surgery. RESULTS: 44 pediatric CD patients (median age 16.5 years) presented with a new ileal stricture during the study period. 30 (68.2%) patients required surgery, with a median time of 87.5 days between stricture diagnosis and surgery. Median stricture measurements were length: 7.0 cm, maximum mural thickness: 7.3 mm, minimum lumen diameter: 0.2 cm, and maximum upstream diameter: 3.3 cm. Median sMaRIA score was 3.0, and 14 (31.8%) strictures had associated internal penetrating disease. Stricture ratio (ratio of maximum upstream lumen diameter to minimum lumen diameter) (OR = 1.15 [95% CI 1.02-1.30]; p = 0.02) and sMaRIA (OR = 2.12 [95% CI 0.87-5.17; p = 0.10) were associated with need for surgery. CONCLUSION: Surgery remains common in stricturing pediatric CD, with increasing stricture ratio and sMaRIA score associated with need for surgical management.

Cardiothoracic Magnetic Resonance Angiography.

Catheter-based angiography is regarded as the clinical reference imaging technique for vessel imaging; however, it is invasive and is currently used for intervention or physiologic measurements. Contrast enhanced magnetic resonance angiography (MRA) with gadolinium-based contrast agents can be performed as a three-dimensional (3D) MRA or as a time resolved 3D (4D) MRA without physiologic synchronization, in which case cardiac and respiratory motion may blur the edges of the vessels and cardiac chambers. Ferumoxytol has recently been a popular contrast agent for MRA in patients with chronic renal failure. Noncontrast 3D MRA with ECG gating and respiratory navigation are safe and accurate noninvasive cross-sectional imaging techniques for the visualization of great vessels of the heart and coronary arteries in a variety of cardiovascular disorders including complex congenital heart diseases. Noncontrast flow dependent MRA techniques such as time of flight, phase contrast, and black-blood MRA techniques can be used as complementary or primary techniques. Here we review both conventional and relatively new contrast enhanced and non-contrast enhanced MRA techniques including ferumoxytol enhanced MRA, and bright-blood and water-fat separation based noncontrast 3D MRA techniques.

Accelerated Cine Cardiac MRI Using Deep Learning-Based Reconstruction: A Systematic Evaluation.

BACKGROUND: Breath-holding (BH) for cine balanced steady state free precession (bSSFP) imaging is challenging for patients with impaired BH capacity. Deep learning-based reconstruction (DLR) of undersampled k-space promises to shorten BHs while preserving image quality and accuracy of ventricular assessment. PURPOSE: To perform a systematic evaluation of DLR of cine bSSFP images from undersampled k-space over a range of acceleration factors. STUDY TYPE: Retrospective. SUBJECTS: Fifteen pectus excavatum patients (mean age 16.8 ± 5.4 years, 20% female) with normal cardiac anatomy and function and 12-second BH capability. FIELD STRENGTH/SEQUENCE: 1.5-T, cine bSSFP. ASSESSMENT: Retrospective DLR was conducted by applying compressed sensitivity encoding (C-SENSE) acceleration to systematically undersample fully sampled k-space cine bSSFP acquisition data over an acceleration/undersampling factor (R) considering a range of 2 to 8. Quality imperceptibility (QI) measures, including structural similarity index measure, were calculated using images reconstructed from fully sampled k-space as a reference. Image quality, including contrast and edge definition, was evaluated for diagnostic adequacy by three readers with varying levels of experience in cardiac MRI (>4 years, >18 years, and 1 year). Automated DL-based biventricular segmentation was performed commercially available software by cardiac radiologists with more than 4 years of experience. STATISTICAL TESTS: Tukey box plots, linear mixed effects model, analysis of variance (ANOVA), weighted kappa, Kruskal-Wallis test, and Wilcoxon signed-rank test were employed as appropriate. A P-value <0.05 was considered statistically significant. RESULTS: There was a significant decrease in the QI values and edge definition scores as R increased. Diagnostically adequate image quality was observed up to R = 5. The effect of R on all biventricular volumetric indices was non-significant (P = 0.447). DATA CONCLUSION: The biventricular volumetric indices obtained from the reconstruction of fully sampled cine bSSFP acquisitions and DLR of the same k-space data undersampled by C-SENSE up to R = 5 may be comparable. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 1.

Comparison of phase contrast magnetic resonance imaging and scintigraphy for determination of split pulmonary blood flow in children and young adults with congenital heart disease.

BACKGROUND: Measurement of differential blood flow to the lungs is important to understanding flow dynamics in the setting of congenital heart disease. Split blood flow via the pulmonary arteries guides and demonstrates the effect of interventions. Minimally invasive imaging of pulmonary blood flow can be achieved with scintigraphy or magnetic resonance imaging (MRI). OBJECTIVE: To assess agreement of pulmonary blood flow measurements obtained by scintigraphy and MRI in children and young adults. MATERIALS AND METHODS: We performed a retrospective review of patients < 21 years of age who had undergone both nuclear medicine pulmonary perfusion scans (Tc-99 m MAA) and cardiac MRI examinations from January 2012 to August 2021 at our tertiary pediatric hospital. Patient demographics, medical/surgical information, and estimates of split blood flow by both modalities were recorded. Pearson's correlation coefficient was used to determine the relationship between split blood flow measured by the two examinations. Agreement was calculated using interclass correlation coefficient (ICC) for absolute agreement and Bland-Altman difference analysis. RESULTS: Correlation between split blood flow measured by scintigraphy and MRI using net flow was 0.90 (95% CI: 0.83-0.94, P < 0.001) and the ICC for agreement on split blood flow was 0.90 (95% CI: 0.84-0.94). Mean difference in split blood flow by Bland-Altman analysis was 0.79% with 95% limits of agreement (-11.2 to 12.8%). CONCLUSION: There is excellent agreement between Tc-99 m scintigraphy and phase contrast MRI for quantification of split pulmonary blood flow in children and young adults with congenital heart disease.

Extracardiac Findings on Cardiac Magnetic Resonance: A Children's Hospital Experience.

Cardiac magnetic resonance (CMR) incorporates a field of view that has the potential to capture clinically relevant extracardiac findings (ECF); however, there has been minimal investigation of ECF prevalence in children's hospitals, where the patient population varies in age and diagnosis. We retrospectively reviewed consecutive, clinically indicated, CMR studies performed at a tertiary care children's hospital during a 1-year period from January 1 to December 31, 2019. ECFs were classified as significant or non-significant based on whether they were described in the final impression of the CMR report. A total of 851 distinct patients had a CMR study during the 1-year period. Mean age was 19.5 (range 0.2; 74.2) years. A total of 254 ECFs were present in 158 of the 851 studies (18.6%) with 9.8% of all studies having significant ECFs. A total of 40.2% of ECFs were previously unknown and 9.1% (23/254) of ECFs included further recommendations (2.1% of all studies). ECFs were most often found in the chest (48%) or abdomen/pelvis (46%). Three patients were incidentally found to have malignancy (renal cell, thyroid, and hepatocellular carcinoma). Comparing studies with significant ECFs to the group without, CMR indications for biventricular CHD (43% vs 31%, p = 0.036), single ventricle CHD (12% vs 3.9%, p = 0.002), and aortopathy/vasculopathy (16% vs 7.6%, p = 0.020) were more common. The odds of significant ECF increased with increasing age (OR 1.82, 95% CI 1.10-3.01) and increased most notably between ages 14 to 33 years old. Recognition of the high percentage of ECFs remains important for timely diagnosis of these incidental findings.

Tentorial Venous Sinuses: A Cadaveric Study.

AIM: To present the configuration of the tentorial venous sinuses, and to determine the optimal incision zone on the tentorium cerebelli. MATERIAL AND METHODS: This study has been completed with 24 autopsied cadavers. For every cadaver, firstly, supratentorial tissues were removed and tentorial measurements were noted, superior part of the tentorial sinuses was captured, and then infratentorial tissues were removed, and all the sinuses were checked and captured. RESULTS: Average age of the studied 24 fresh cadavers was 50 years, wherein 4 were females and 20 were males. Tentorial sinus was presented in 87% of the cases, with 45% medial, 33% lateral, and 22% in the middle third of each tentorium half. CONCLUSION: This study showed the pattern, incidence, location, and distribution of tentorial venous sinuses and tried to find the optimum incision zone by identifying sparse areas for the venous sinuses during transtentorial surgical approaches.

Myocardial Parametric Mapping by Cardiac Magnetic Resonance Imaging in Pediatric Cardiology and Congenital Heart Disease.

Parametric mapping, that is, a pixel-wise map of magnetic relaxation parameters, expands the diagnostic potential of cardiac magnetic resonance by enabling quantification of myocardial tissue-specific magnetic relaxation on an absolute scale. Parametric mapping includes T1 mapping (native and postcontrast), T2 and T2* mapping, and extracellular volume measurements. The myocardial composition is altered in various disease states affecting its inherent magnetic properties and thus the myocardial relaxation times that can be directly quantified using parametric mapping. Parametric mapping helps in the diagnosis of nonfocal disease states and allows for longitudinal disease monitoring, evaluating therapeutic response (as in Thalassemia patients with iron overload undergoing chelation), and risk-stratification of certain diseases. In this review article, we describe various mapping techniques and their clinical utility in congenital heart disease. We will also review the available literature on normative values in children, the strengths, and weaknesses of these techniques. This review provides a starting point for pediatric cardiologists to understand and implement parametric mapping in their practice.

Patient- and Examination-Related Predictors of 3D MRCP Image Quality in Children.

BACKGROUND. MRCP provides noninvasive imaging of the biliary tree and pancreatic duct. In our experience, MRCP image quality is commonly suboptimal in children. OBJECTIVE. The purpose of this study was to characterize the frequency of nondi-agnostic 3D fast spin-echo (FSE) MRCP acquisitions and determine predictors of nondi-agnostic MRCP image quality in children. METHODS. This retrospective study included 200 randomly selected pediatric patients (101 female and 99 male patients; mean age, 11.7 years) who underwent MRCP between January 1, 2019, and December 31, 2020. Patient- and examination-related variables were recorded. Three fellowship-trained pediatric radiologists independently reviewed 3D FSE MRCP acquisitions for diagnostic quality (diagnostic vs nondiagnostic) and overall image quality score on a scale from 1 to 5 (1 = worst image quality imaginable, 5 = best image quality imaginable). After computing interreader agreement, analyses used readers' most common diagnostic quality assessment and mean image quality score. Multivariable logistic regression and linear regression analyses were used to identify predictor variables of a diagnostic examination and higher image quality score. RESULTS. Interreader agreement for an MRCP acquisition being diagnostic quality, expressed as a kappa coefficient, was 0.53-0.71; interreader agreement for image quality score, expressed as an intraclass correlation coefficient, was 0.68-0.74. A total of 36 of 200 (18%) MRCP acquisitions were nondiagnostic; the mean image quality score was 3.5 ± 1.1 (SD). Multivariable predictors of a diagnostic MRCP acquisition included greater body mass index (OR = 1.11 [95% CI, 1.02-1.21]; p = .02), scanner field strength of 1.5 T (odds ratio [OR] = 2.87 [95% CI, 1.23-6.68]; p = .01), and presence of acute pancreatitis (OR = 4.91 [95% CI, 1.53-15.77]; p = .008). Multivariable predictors of a higher image quality score (ß = 0.05-0.94) included older age (p = .01), imaging performed with patient under sedation or general anesthesia (p < .001), presence of biliary dilatation (p = .004), and inpatient status (p = .02). A lower image quality score was predicted by a scanner field strength of 3 T (ß = -0.61; p < .001). A greater amount of time between the start of the MRI examination and the MRCP acquisition exhibited a nonsignificant association with a decrease in the image quality score (p = .06). CONCLUSION. Pediatric MRCP acquisitions are commonly nondiagnostic. Patient-specific and technical factors systematically impact MRCP image quality in children. CLINICAL IMPACT. Recognition of image quality predictors that are potentially modifiable and amendable to proactive intervention can guide efforts to optimize MRCP image quality in children.

Quantitative assessment of velocity and flow using compressed SENSE in children and young adults with adequate acquired temporal resolution.

BACKGROUND: Phase contrast (PC) cardiovascular magnetic resonance (CMR) imaging with parallel imaging acceleration is established and validated for measuring velocity and flow. However, additional acceleration to further shorten acquisition times would be beneficial in patients with complex vasculature who need multiple PC-CMR measurements, especially pediatric patients with higher heart rates. METHODS: PC-CMR images acquired with compressed sensitivity encoding (C-SENSE) factors of 3 to 6 and standard of care PC-CMR with sensitivity encoding (SENSE) factor of 2 (S2) acquired as part of clinical CMR examinations performed between November 2020 and January 2021 were analyzed retrospectively. The velocity and flow through the ascending aorta (AAo), descending aorta (DAo), and superior vena cava (SVC) in a transverse plane at the level of pulmonary artery bifurcation were compared. Additionally, frequency power distribution and dynamic time warp distance were calculated for these acquisitions. To further validate the adequate temporal resolution requirement, patients with S2 PC-CMR in the same acquisition plane were added in frequency power distribution analysis. RESULTS: Twenty-eight patients (25 males; 15.9 ± 1.9 years; body surface area (BSA) 1.7 ± 0.2 m2; heart rate 81 ± 16 bpm) underwent all five PC-CMR acquisitions during the study period. An additional 22 patients (16 males; 17.5 ± 7.7 years; BSA 1.6 ± 0.5 m2; heart rate 91 ± 16 bpm) were included for frequency power spectrum analysis. As expected, scan time decreased with increasing C-SENSE acceleration factor = 3 (37.5 ± 6.5 s, 26.4 ± 7.6%), 4 (28.1 ± 4.9 s, 44.7 ± 5.6%), 5 (21.6 ± 3.6 s, 57.6 ± 4.4%), and 6 (19.1 ± 3.2 s, 62.3 ± 4.2%) relative to SENSE = 2 (51.3 ± 10.1 s) PC-CMR acquisition. Mean peak velocity, net flow, and cardiac output were comparable (p > 0.87) between the five PC-CMR acquisitions with mean differences less than < 4%, < 2%, and < 3% respectively. All individual blood vessels showed a non-significant dependence of difference in fmax99 (< 4 Hz, p > 0.2), and dynamic time warp distance (p > 0.3) on the C-SENSE acceleration factor used. There was a strongly correlated (r = 0.74) increase in fmax99 (10.5 ± 2.2, range: 7.1-16.4 Hz) with increasing heart rate. The computed minimum required cardiac phase number was 15 ± 2.0 (range: 11-20) over the heart rate of 86 ± 15 bpm (range: 58-113 bpm). CONCLUSIONS: Stroke volume, cardiac output, and mean peak velocity measurements using PC-CMR with C-SENSE of up to 6 agree with measurements by standard of care PC-CMR with SENSE = 2 and resulted in up to a 65% reduction in acquisition time. Adequate temporal sampling can be ensured by acquiring 20 cardiac phases throughout the entire cardiac cycle over a wide range of pediatric and young adult heart rates.

The Supracerebellar Transtentorial Approach in the Prone Position.

The mediobasal temporal region (MTR) is a deep part of the brain covered by eloquent structures. In certain cases, accessing this region is challenging. According to the literature, the supracerebellar transtentorial (SCTT) approach provides safe access to the MTR. Since this approach was introduced by Voigt and Yasargil, many researchers used SCTT in different positions. In particular, the sitting position was the most preferred as it allows the cerebellum to fall away from the tentorium. However, this position has disadvantages such as venous air embolism (VAE), paradoxical air embolism (PAE), and some non ergonomic conditions during surgery. We report two cases with tumors affecting the middle and posterior medial temporal regions. Both patients underwent surgeries in the prone position using the SCTT approach. There were no procedure-related complications. Histopathological results were as follows: psammomatous meningioma in the first case; adenocarcinoma metastasis in the second case. Thus, in this study, the efficacy, feasibility, and safety of accessing the MTR using the SCTT approach in the prone position were demonstrated.

Breath-hold and free-breathing quantitative assessment of biventricular volume and function using compressed SENSE: a clinical validation in children and young adults.

BACKGROUND: Although the breath-hold cine balanced steady state free precession (bSSFP) imaging is well established for assessment of biventricular volumes and function, shorter breath-hold times or no breath-holds are beneficial in children and severely ill or sedated patients. METHODS: Clinical cardiovascular magnetic resonance (CMR) examinations from September 2019 to October 2019 that included breath-hold (BH) and free-breathing (FB) cine bSSFP imaging accelerated using compressed sensitivity encoding (C-SENSE) factor of 3 in addition to the clinical standard BH cine bSSFP imaging using SENSE factor of 2 were analyzed retrospectively. Patients with structurally normal hearts who could perform consistent BHs were included. Aortic flow measured by phase contrast acquisition was used as a reference for the left ventricular (LV) stroke volume. Comparative analysis was performed for evaluation of biventricular volumes and function, imaging times, quantitative image quality, and qualitative image scoring. RESULTS: There were 26 patients who underwent all three cine scans during the study period (16.7 ± 6.4 years, body surface area (BSA) 1.6 ± 0.4 m2, heart rate 83 ± 7 beats/min). BH durations of 8 ± 1 s with C-SENSE = 3 were significantly shorter (p < 0.001) by 33% compared to 12 ± 1 s with SENSE = 2. Actual scan time for BH SENSE (4.9 ± 1.2 min) was comparable to that with FB C-SENSE (5.2 ± 1.5 min; p= NS). Biventricular stroke volume and ejection fraction, and LV mass computed using all three sequences were comparable. There was a small but statistically significant (p < 0.05) difference in LV end-diastolic volume (- 3.0 ± 6.8 ml) between BH SENSE and FB C-SENSE. There was a small but statistically significant (p < 0.005) difference in end-diastolic LV (- 5.0 ± 7.7 ml) and RV (- 6.0 ± 8.5 ml) volume and end-systolic LV (- 3.2 ± 4.3 ml) and RV(- 4.2 ± 6.8 ml) volumes between BH C-SENSE and FB C-SENSE. The LV stroke volumes from all three sequences had excellent correlations (r = 0.96, slope = 0.98-1.02) with aortic flow, with overestimation by 2.7 (5%) to 4.6 (8%) ml/beat. The image quality score was Excellent (16 of 26) to Good (10 of 26) with BH SENSE, Excellent (13 of 26) to Good (13 of 26) with BH C-SENSE, and Excellent (3 of 26) to Good (21 of 26) to Adequate (2 of 26) with FB C-SENSE. CONCLUSIONS: Image quality and ventricular volumetric and functional indices using either BH or FB C-SENSE cine bSSFP imaging were comparable to standard BH SENSE cine bSSFP imaging while maintaining nominally identical spatio-temporal resolution. This accelerated image acquisition provides an alternative to accommodate patients with impaired BH capacity.

Magnetic resonance imaging of the fetal brain in monochorionic diamniotic twin gestation: correlation of cerebral injury with ultrasound staging and survival outcomes.

BACKGROUND: The current staging system of twin-twin transfusion syndrome (TTTS) is based on the ultrasound criteria and does not consider the cerebral injury. OBJECTIVE: To assess the incidence of cerebral damage on fetal MRI and correlate abnormal cerebral diffusion-weighted imaging (DWI) findings with survival outcome and the ultrasound staging of TTTS. MATERIALS AND METHODS: We conducted a retrospective review of MRI/DWI of fetal brains and the electronic medical records in monochorionic diamniotic twin gestations. Axial DWI of each fetal brain was performed on 1.5-tesla (T) clinical magnet with b values of 0 s/mm2 and 700 s/mm2. We correlated MRI/DWI abnormalities with the Quintero staging system and survival outcomes of the fetuses. RESULTS: Thirty-four pregnancies (68 fetuses) with 42 fetal cerebral abnormalities were identified by MRI/DWI alone. Of these 42 fetal cerebral abnormalities, 33 fetal brain lesions were visible only on DWI (n=25 donor, n=8 recipients; n=30 unilateral, n=3 bilateral; n=26 diffuse, n=7 focal). Quintero staging in these 34 pregnancies was as follows: 9 Stage I, 7 Stage II, 13 Stage III, 4 Stage IV, 1 Stage V. There was no significant correlation between the presence of cerebral infarction or hemorrhage using MRI/DWI and ultrasound staging (P=0.138). The overall survival rate was 63.2% (43/68). There was a significant correlation between the presence of cerebral infarction or hemorrhage on MRI/DWI and delivery status (P=0.009). CONCLUSION: Abnormal cerebral imaging findings on MRI/DWI from hypoxic-ischemic injury or hemorrhage can be seen at the beginning of the second trimester and do not correlate with the current ultrasound staging system; however, they do correlate with decreased survival. Fetal cerebral abnormalities could be incorporated into the TTTS staging system as an independent risk factor.

Comparison of Subthalamic Nucleus vs. Globus Pallidus Interna Deep Brain Stimulation in Terms of Gait and Balance; A Two Year Follow-Up Study.

AIM: To compare the effects of subthalamic nucleus (STN) and globus pallidus interna (GPi) deep brain stimulation (DBS) on the motor outcome, gait and balance function, fall risk (FR), and non-motor symptoms in patients with advanced Parkinson's disease (PD). MATERIAL AND METHODS: We randomized patients with advanced PD with the indication of DBS to undergo either STN or GPi DBS and followed them for 2 years. We collected data at baseline and postoperative 6, 12, and 24 months. We compared changes in the Unified Parkinson's Disease Rating Scale (UPDRS) score, timed gait tests, posturography, non-motor symptom questionnaire (NMSQuest), hospital anxiety and depression (HAD) scale, and levodopa equivalent dose (LED). RESULTS: We enrolled and randomized 12 patients to receive either STN (n = 6) or GPi (n = 6) DBS. Postoperative motor outcomes were significantly improved in both groups (p < 0.05). In both groups, timed gait tests exhibited better performance in mobility; however, patients receiving GPi DBS performed better than those receiving STN DBS in the timed gait tests (p < 0.05). Furthermore, the posturographic evaluation demonstrated a significant elevation in the FR in the STN group (p < 0.05). CONCLUSION: Both STN and GPi DBS are equally effective in alleviating disabling motor complications. However, seemingly, STN DBS could cause more gait and balance problems; hence, a tailored approach seems to be more appropriate in the target selection.

Natural Course of Myxopapillary Ependymoma: Unusual Case Report and Review of Literature.

BACKGROUND: Spinal cord ependymomas are the most frequent primary intramedullary tumors of the cord in middle age (40-60 years of age). Myxopapillary ependymomas are low-incidence tumors and occur in the cauda equina and conus medullaris. They are typically described as fleshy, sausage-shaped, vascular lesions. CASE DESCRIPTION: In this report, we present a 36-year-old woman who was seen in another hospital with complaints of back pain radiating into both legs 5 years ago. Magnetic resonance imaging (MRI) examinations revealed a lesion releated to the spinal cord. At that point, the patient refused the proposed surgical treatment. Five years later, the patient was referred to our clinic with advancement of the complaint to paraparesis. The new MRI showed an intradural mass at the level of T11 and S1. We performed a total intradural tumor resection. Histopathologic examination revealed a myxopapillary ependymoma. CONCLUSIONS: Myxopapillary ependymomas grow slowly and are well defined by MRI. Advancements in radiologic technology and surgical equipment have allowed this tumor type to be treated successfully. Unfortunately, if untreated, these lesions have poor prognosis and result in clinical symptoms such as paraparesis. Surgical treatment of these lesions using total resection was performed total resection and was associated with an excellent postoperative outcome. We highlight the natural course of myxopapillary ependymomas.

The role of diffusion-weighted imaging in prediction liver iron concentration in beta-thalassaemia patients.

OBJECTIVE: The aim of this study was to analyse the value of diffusion-weighted magnetic resonance imaging (DWI) to determine the liver parenchyma iron concentration in ß-thalassaemia major patients. METHODS: Abdominal magnetic resonance (MR) imaging, including gradient echo sequences and DWI sequences, was undertaken of 55 ß-thalassaemia major patients. The apparent diffusion coefficient (ADC) values of liver parenchyma were measured in seven regions at the level of the portal bifurcation and compared with liver iron concentration (LIC). Patients with normal and mild liver dry weight (LDW) results were classified as group 1, whereas patients with moderate and severe values were classified as group 2. RESULTS: There was a dramatic decrease in ADC values as the severity of LIC increased. The median ADC values were 1.6-1.9 × 10-3  mm2 /sec in group 1 and 0.6-0.9 × 10-3  mm2 /sec in group 2. A negative correlation was observed between ADC and the LDW values in both groups. The ADC and LIC correlation in each subgroup was statistically significant with asymptotic 95% confidence intervals of 0.820-0.997. CONCLUSION: Diffusion-weighted imaging is sensitive to tissue changes as a result of iron accumulation and may be used to predict liver iron overload in ß-thalassaemia major patients with a high sensitivity and specificity.

Isolated Persistent Left Superior Vena Cava, Sick Sinus Syndrome, and Challenging Pacemaker Implantation.

Persistent left superior vena cava with absent right superior vena cava is a very rare venous anomaly and is known as isolated PLSVC. It is usually an asymptomatic anomaly and is mostly detected during difficult central venous access or pacemaker implantation, though it could also be associated with an increased incidence of congenital heart disease, arrhythmias, and conduction disturbances. Herein, we describe a dual-chamber pacemaker implantation in a patient with isolated PLSVC and sick sinus syndrome.

The middle interhemispheric variant of holoprosencephaly: magnetic resonance and diffusion tensor imaging findings.

OBJECTIVE: The middle interhemispheric (MIH) variant of holoprosencephaly (HPE) is the incomplete separation of midline cerebral hemispheres with the absence of callosal body. We aimed to describe the additional knowledge of diffusion tensor imaging (DTI) over conventional MRI in the evaluation of patients with MIH variant of HPE. METHODS: Conventional MRI and DTI data of five patients were retrospectively evaluated. The parenchymal anomalies as well as changes at white matter tracts were systematically reviewed. RESULTS: Except the callosal body and central cingulum fibres, which were missing in all patients, all other major white matter tracts (superior and inferior longitudinal, superior and inferior fronto-occipital, subcallosal and uncinate fasciculi and anterior commissure) had a normal course, thickness and integrity on diffusion tensor images. The genial and splenial callosal fibres were altered and rarefied on tractography. All patients had a central ventricular notch extending into the non-cleaved heterotopic grey matter involving the body of the corpus callosum, which is very typical for the MIH variant of HPE. The remnant traversing white matter fibres above the non-cleaved heterotopic grey matter and incomplete partition of the interhemispheric fissure were also identified. No Probst bundles were detected. A single common ventricle without the septum pellucidum was noted in all patients. One patient had incomplete partition of the thalami, and two patients had abnormally oriented thalami without any prominent interthalamic connection. Vertically oriented hippocampi were detected in four out of five patients. Three patients had relatively flat and vertically oriented Sylvian fissures and in two patients, fissures were abnormally connected over the vertex. CONCLUSION: Additional DTI findings can not only clearly reveal the white matter alterations better than conventional MRI but also provide a better understanding of the aetiological changes that cause the MIH variant of HPE. ADVANCES IN KNOWLEDGE: DTI can provide a better analysis of cerebral white matter connectivity and promotes understanding of the underlying microstructural changes that occur in patients with the MIH variant of HPE.