T cell vaccination in multiple sclerosis relapsing-remitting nonresponders patients.

Myelin autoreactive T cells are involved in the pathogenesis of multiple sclerosis (MS) and lead to propagation of the disease. We evaluated the efficacy of T cell vaccination (TCV) therapy for patients with aggressive relapsing-remitting MS who failed to respond to immunomodulatory treatments. Twenty nonresponders relapsing-remitting MS patients were immunized with autologous attenuated T cell lines after activation with synthetic myelin basic protein (MBP) and myelin oligodendrocyte glycoprotein (MOG) encephalitogenic peptides. Each patient received three vaccinations in 6- to 8-week intervals. Annual relapse rate decreased from 2.6 to 1.1, P = 0.026. Neurological disability stabilized as compared with the 2- and 1-year pretreatment progression rates. Significant reduction in the number and volume of active lesions, as well as reduction in T2 lesion burden, was demonstrated by quantitative MRI analysis. No serious adverse events were observed. Our findings suggest that TCV has beneficial clinical effects in MS patients who, in spite of immunomodulatory treatments, continue to deteriorate. TCV could serve as a potential alternative therapy for this subgroup of nonresponders patients.

Laryngo-tracheal anastomosis: post-operative evaluation by helical CT and computerized reformations.

OBJECTIVE: Our purpose was to evaluate the role of post-operative helical computed tomography (CT) and computerized reformations in patients after laryngo-tracheal segmental resection with anastomosis. METHODS: Helical CT and computerized reformations were obtained in 11 consecutive patients who underwent laryngo-tracheal resection with anastomosis for obstruction or stenosis caused by longstanding intubation or tracheostomy. Post-operative computer assisted cross-sectional area, coronal and sagittal diameter measurements at the level of maximal narrowing of the trachea were compared with clinical assessment in all patients. The additive value of various coronal and sagittal computerized reformations over axial images was subjectively evaluated by a consensus of a thoracic radiologist and a neuroradiologist who were blinded to clinical information. RESULTS: Various degrees of restriction in daily activities were reported by patients with cross-sectional area narrowing of more than 50%, by 4/6 patients with cross-sectional area of less than 90mm(2), by 4/5 and 4/6 patients with coronal or sagittal narrowing of more than 25% respectively, and by 4/5 patients with sagittal diameter of less than 12mm. All five patients with cross-sectional area stenosis of less than 50% assessed themselves as 'asymptomatic'. Sagittal multi-planar and volume rendering reformations clarified or added additional information over axial images in all six patients with significant cross-sectional area stenosis (>50%). Volume rendering scores were significantly higher than minimal intensity projection reformations (P=0.01). CONCLUSION: Our preliminary results suggest that CT-based cross-sectional area and diameter measurements of the trachea represent a clinically helpful tool for post-operative evaluation of patients with tracheoplasty. The need for post-operative endoscopy may be obviated in some cases.

Intraoperative magnetic resonance imaging-guided drainage of nonpalpable abscesses.

SUMMARY: Intraoperative magnetic resonance imaging provides the surgeon with powerful, high-resolution, real-time imaging. Procedures may be performed with minimal invasion, with the benefit of reduced tissue damage, improved wound healing, and a better cosmetic result. The authors present a case of a leukemic pediatric patient with a few large, deeply situated, nonpalpable abscesses that were drained successfully with intraoperative magnetic resonance imaging guidance. In this case, this new intraoperative imaging method enabled minimal invasiveness, with fast recovery.

Monitoring response to convection-enhanced taxol delivery in brain tumor patients using diffusion-weighted magnetic resonance imaging.

Convection-enhanced drug delivery (CEDD) is a novel approach to enhance the delivery of drugs directly into brain tumors. We have used diffusion-weighted MRI (DWMRI) to monitor the effects of intratumoral CEDD in three brain tumor patients treated with Taxol. Clear changes in the images and the water diffusion parameters were observed shortly after the initiation of treatment. Initially, a bright area corresponding to decreased diffusion appeared, followed by the appearance of a dark area of increased diffusion within the bright area. The time to appearance of the dark area varied among the patients, suggesting different response rates. In this work, we have demonstrated the feasibility of using DWMRI as a noninvasive tool to achieve unique early tissue characterization not attainable by other conventional imaging methods.

The value of the occipitomental (Waters') view in diagnosis of sinusitis: a comparative study with computed tomography.

AIM: Sinus X-rays are still frequently used in the evaluation of paranasal sinusitis. Many radiology departments nowadays provide the referring doctors with a single Waters' projection. Our purpose was to evaluate the diagnostic accuracy of a single Waters' view vs high resolution computed tomography (CT) in the diagnosis of paranasal sinusitis. SUBJECTS AND METHODS: A total of 134 patients with suspected paranasal sinusitis underwent a Waters' view X-ray and high resolution CT on the same day. The radiographs were evaluated independently by nine experienced radiologists, who observed each sinus separately. Sensitivity, specificity, accuracy, positive and negative predictive values were calculated for each sinus and for each observer, using the CT findings as a 'gold standard'. RESULTS: The weighted mean sensitivity for diagnosis of any abnormality in the maxillary sinus was 67.7%, specificity 87.6%, accuracy 78.6%, positive predictive value 82.5% and negative predictive value 76.9%. For this sinus the variation between observers was small, however, the sensitivity for diagnosis of any disease in the frontal and ethmoid sinuses varied widely between observers (range 1.9-54.0% and 0-58.9%, respectively). The sensitivity for the sphenoid sinus was very low (range 0-3.8%), even in radiographs which seemed to demonstrate it well. CONCLUSION: The Waters' view has its limits in the diagnosis of sinusitis of the maxillary sinuses and its contribution for diagnosing lesions in the remaining sinuses is very poor. Whenever access to CT is available, a low dose high-resolution CT study of the paranasal sinuses is highly recommended.Konen, E. (2000). Clinical Radiology55, 856-860.

Acquired tracheoesophageal fistula in critically ill patients.

Acquired benign tracheoesophageal fistula (TEF) is an infrequent complication of prolonged intubation and tracheostomy. Not infrequently, it is associated with severe circumferential malacia of the trachea and a need for concomitant correction of both. Controversy exists as to whether this should be performed in a single-stage or a 2-stage procedure. Four patients with acquired TEF underwent operation in a tertiary referral medical center between 1995 and 1997. The operations were performed through either an anterior (3) or a lateral (1) neck approach. Three patients underwent closure of the fistula with tracheal resection and anastomosis in a single stage and are doing well. One patient with complete subglottic stenosis underwent closure of the TEF and was planned for tracheal reconstruction in a second stage. This patient died in the early postoperative period. The complications included aspiration of blood leading to pneumonia (2), spontaneously resolving pneumomediastinum (1), subcutaneous emphysema (2), and cardiac arrhythmia ( 1). Residual fistula, noted in 1 patient, was treated conservatively and resolved spontaneously within several weeks. We conclude that acquired TEF is amenable to repair through a cervical approach. A single-stage correction of the TEF with reconstruction of the trachea is suitable and successful in most patients. Several stages seem justified when concurrent laryngotracheal reconstruction is needed.

Automated detection and characterization of multiple sclerosis lesions in brain MR images.

In the present study an automatic algorithm for detection and contouring of multiple sclerosis (MS) lesions in brain magnetic resonance (MR) images is introduced. This algorithm automatically detects MS lesions in axial proton density, T2-weighted, gadolinium enhanced, and fast fluid attenuated inversion recovery (FLAIR) brain MR images. Automated detection consists of three main stages: (1) detection and contouring of all hyperintense signal regions within the image; (2) partial elimination of false positive segments (defined herein as artifacts) by size, shape index, and anatomical location; (3) the use of an artificial neural paradigm (Back-Propagation) for final removal of artifacts by differentiating them from true MS lesions. The algorithm was applied to 45 images acquired from 14 MS patients. The algorithm's sensitivity was 0.87 and the specificity 0.96. In 34 images, 100% of the lesions were detected. The algorithm potentially may serve as a useful preprocessing tool for quantitative MS monitoring via magnetic resonance imaging.

Heat-stroke-induced cerebellar atrophy: clinical course, CT and MRI findings.

We report the clinical course and CT and MRI findings in a case of heat-stroke-induced cerebellar atrophy. Although the cerebellar syndrome was severe concomitant with the onset of heat stroke, no abnormality was observed on brain CT in the first 2 weeks following the event. Cerebellar atrophy was first noted after 10 weeks on MRI; it was progressive during a 1-year follow-up.

[Brain imaging and its clinical application in psychiatry].

The common structural and functional brain imaging techniques are described from a practical, clinical point of view. The clinical indications for brain imaging in psychiatry are reviewed in relation to the specific limitations and advantages of each technique. The clinical applications of computerized tomography (CT), magnetic resonance imaging (MRI) and single photon emission computerized tomography (SPECT) are discussed in relation to the differential diagnosis between organic and functional psychiatric disorders. In a 55-year-old man with late onset of behavioral changes but without neurological signs the application of structural brain imaging (CT and MRI) in case management was demonstrated. The imaging findings involved the differential diagnosis between depression and focal brain lesions. In a 38-year-old man with personality changes and depression following a traumatic brain injury, time interval repeated functional brain imaging (SPECT) was used. Brain imaging reflected improvement in clinical status following treatment and was able to differentiate between reversible and permanent traumatic brain injuries. The superior yield of time interval repeated functional imaging in diagnosis and management of postconcussion syndrome is discussed.

Vocal cords dysfunction resulting from heterotopic ossification in a patient with burns.

Limitation of movement of vocal cords developed in a 38-year-old man after he received a 45% second- and third-degree burn with ossification about the cricoarytenoid joints, which indicated that the lesion had been caused by heterotropic ossification. To the best of our knowledge, this is the first report in medical literature of heterotopic ossification as a mechanical cause of vocal cords dysfunction in the patient with critical burns. Diphosphonate (Didronel) treatment has improved the function of the vocal cords after 11 months of therapy.

CT target selection in stereotactic anterior capsulotomy: anatomical considerations.

The first communications concerning stereotactic bilateral anterior capsulotomies were reported by Talairach and Leksell. This procedure has become established for the management of otherwise intractable anxiety neuroses and obsessive compulsive disorders, with a reported success rate of 70% in different series. It has been stressed that results are closely related to the extent of the lesion. The desirable lesion has a tubular shape with a length of 15-18 mm in the coronal axis. This shape is achieved by step withdrawal of a 4- to 5-mm electrode tip along a proper trajectory. A precise angulation of the trajectory is crucial to proceed without lesioning of the adjacent bordering caudate nucleus or putamen in the coronal plane. In the sagittal plane, it has to remain within the limits of the anterior capsula interna and avoid an excessive posteroanterior obliquity to ensure that the entry point through the cortex remains in the prefrontal noneloquent area. To achieve this trajectory, a target 5 mm posterior to the anterior border of the frontal horn, as seen on CT, at the level of the foramen of Monro has been suggested, along with a precoronal burr hole placed 20 degrees from the midline. Following these guidelines we have found the resulting lesions to be excessively anterior, with exclusion of their first 4- to 5-mm deep component. If the same target point is selected at two different axial levels to fix a trajectory, it usually results in an anteriorward trajectory that might require an entry point too close to the motor cortex, because the anterior horn reaches more rostrally as it deepens.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of pediatric brain tumors in a tertiary center.

Between January 1982 and January 1990, 120 newly diagnosed pediatric patients were treated at The Chaim Sheba Medical Center. Sixty three (52.5%) tumors arose in the posterior fossa and 57 (47.5%) appeared supratentorially. A wide variety of histologic subtypes was seen, each requiring tumor-specific treatment. The modern imaging techniques-CT and MRI-offered better planning of operation, treatment and follow up. All children with highly malignant tumors were treated with combination chemotherapy besides the 'conventional radiotherapy'. Since 1987 the "eight in one day" protocol has been used extensively pre- and post-irradiation. Five-year survival, varied significantly according to tumor type, location and stage. The average delay from presentation of symptoms to diagnosis was 6 months. A multidisciplinary approach has been used in the treatment, rehabilitation and follow-up of these children. In this study, the results of treatment are presented and the role of chemotherapy is discussed.

Migration of fishbone following penetration of the cervical esophagus presenting as a thyroid mass.

Fishbones are among the commonest foreign bodies lodged in the cervical esophagus. A small percentage of them will penetrate the esophageal wall and will be found either intra- or extraluminally. Migration of esophageal foreign bodies to the thyroid gland, and presentation as a mass, is extremely rare. We present such a case and review the relevant literature.

Postoperative spinal epidural empyema. Clinical and computed tomography features.

Epidural empyema is a rare complication of elective spinal surgery. Four such cases are described. The clinical features of this postoperative complication were surprisingly vague and misleading. Fever was uncommon. Local inflammatory signs or rapid neurologic deterioration were absent. Computerized tomography proved useful in diagnosis and follow-up. Unlike spontaneous spinal epidural abscess, postoperative spinal epidural empyema had a benign course. Causative bacteria were miscellaneous. Surgical evacuation of the purulent collection and appropriate antibiotic therapy resulted in cure in all cases.

Upward transtentorial herniation: a complication of postoperative edema at the cervicomedullary junction.

Local edema at the operative bed developed a few hours after uneventful subtotal removal of a lesion occupying the lower medulla and upper cervical cord. The patient experienced apnea, quadriplegia, and circulatory collapse followed by acute respiratory insufficiency. Hydrocephalus secondary to aqueductal occlusion occurred on the 3rd postoperative day. A computerized tomographic scan was compatible with upward transtentorial herniation. The association of this phenomenon with an intra-axial lesion at the cervicomedullary junction has not been previously documented. The pathophysiological mechanisms implicated in this complication are discussed.