Imaging Differences between Neuromyelitis Optica Spectrum Disorders and Multiple Sclerosis: A Multi-Institutional Study in Japan.

BACKGROUND AND PURPOSE: Both clinical and imaging criteria must be met to diagnose neuromyelitis optica spectrum disorders and multiple sclerosis. However, neuromyelitis optica spectrum disorders are often misdiagnosed as MS because of an overlap in MR imaging features. The purpose of this study was to confirm imaging differences between neuromyelitis optica spectrum disorders and MS with visually detailed quantitative analyses of large-sample data. MATERIALS AND METHODS: We retrospectively examined 89 consecutive patients with neuromyelitis optica spectrum disorders (median age, 51 years; range, 16-85 years; females, 77; aquaporin 4 immunoglobulin G-positive, 93%) and 89 with MS (median age, 36 years; range, 18-67 years; females, 68; relapsing-remitting MS, 89%; primary-progressive MS, 7%; secondary-progressive MS, 2%) from 9 institutions across Japan (April 2008 to December 2012). Two neuroradiologists visually evaluated the number, location, and size of all lesions using the Mann-Whitney U test or the Fisher exact test. RESULTS: We enrolled 79 patients with neuromyelitis optica spectrum disorders and 87 with MS for brain analysis, 57 with neuromyelitis optica spectrum disorders and 55 with MS for spinal cord analysis, and 42 with neuromyelitis optica spectrum disorders and 14 with MS for optic nerve analysis. We identified 911 brain lesions in neuromyelitis optica spectrum disorders, 1659 brain lesions in MS, 86 spinal cord lesions in neuromyelitis optica spectrum disorders, and 102 spinal cord lesions in MS. The frequencies of periventricular white matter and deep white matter lesions were 17% and 68% in neuromyelitis optica spectrum disorders versus 41% and 42% in MS, respectively (location of brain lesions, P < .001). We found a significant difference in the distribution of spinal cord lesions between these 2 diseases (P = .024): More thoracic lesions than cervical lesions were present in neuromyelitis optica spectrum disorders (cervical versus thoracic, 29% versus 71%), whereas they were equally distributed in MS (46% versus 54%). Furthermore, thoracic lesions were significantly longer than cervical lesions in neuromyelitis optica spectrum disorders (P = .001), but not in MS (P = .80). CONCLUSIONS: Visually detailed quantitative analyses confirmed imaging differences, especially in brain and spinal cord lesions, between neuromyelitis optica spectrum disorders and MS. These observations may have clinical implications.

Internal anomalies in thalidomide embryopathy: results of imaging screening by CT and MRI.

AIM: To examine the prevalence and detailed radiological findings of internal anomalies in thalidomide embryopathy (TE). MATERIALS AND METHODS: Whole-body image screening for internal anomalies using unenhanced whole-body computed tomography (CT) and head magnetic resonance imaging (MRI) was performed in 22 patients (13 women and nine men; mean age, 49 years; range, 47-51 years) with TE. RESULTS: Among the 22 patients with TE, internal anomalies were detected in 19 (86.4%): anomalies of the auditory organ in 10 (45.5%), anomalies of the vascular system in six (27.3%), agenesis of the gallbladder in six (27.3%), hypoplasia or aplasia of the 7th or 8th cranial nerves in five (22.7%), block vertebrae in five (22.7%), fusion of the left lobe and quadrate lobe of the liver in three (9.1%), and others in five (22.7%), respectively. CONCLUSION: In addition to limb defects or hypoplasia, various internal anomalies can be detected at a high incidence in TE using CT and MRI. Understanding these characteristic radiological findings may help radiologists detect a wide range of radiological findings of internal anomalies associated with TE.

Diffuse Liver Metastasis of Small-Cell Lung Cancer Presenting as Acute Liver Failure and Diagnosed by Transjugular Liver Biopsy: A Rare Case in Whom Nodular Lesions Were Detected by Enhanced CT Examination.

Small-cell lung cancer (SCLC) is a subgroup of lung cancer with a high frequency of liver metastasis, which is a predictor of poor prognosis. Diffuse liver metastases of SCLC with no visible nodular lesions in the liver when examined using computed tomography (CT) are relatively rare; however, a few cases with rapid progression to acute liver failure that were diagnosed after death have been reported. In this paper, we report a 63-year-old man with diffuse liver metastases of SCLC that were histologically diagnosed using a transjugular liver biopsy while the patient was alive, even though no lesions were visible during a contrast-enhanced CT examination.

Traumatic persistent trigeminal artery--cavernous sinus fistula treated by transcatheter arterial embolization. A case report.

We describe a rare case of traumatic persistent trigeminal artery (PTA) - cavernous sinus fistula. Cerebral angiography showed direct communication between the right PTA and the cavernous sinus which was treated by transcathether arterial embolization. Although previous reports have indicated the use of more coils to treat this condition, we successfully treated the patient with only two coils placed near the orifice of the fistula after sufficient anatomical evaluation.

Hepatic falciform artery: angiographic observations and significance.

BACKGROUND: The purpose of this study was to assess the angiographic incidence and appearance of the hepatic falciform artery (HFA) and discuss its clinical significance. METHODS: Hepatic angiograms of 53 patients obtained with digital subtraction angiography were prospectively evaluated with regard to incidence, anatomic features, and flow speed of the HFA. We analyzed whether the background of chronic liver disease affected the incidence of the HFA. Transcatheter arterial chemoinfusion or chemoembolization for liver tumors was performed in 33 patients. We noted the occurrence of supraumbilical skin complications. RESULTS: The HFA was observed in 13 (24.5%) of 53 patients on celiac or common hepatic angiograms. The blood flow of the HFA was slower than that of the peripheral hepatic arteries in all patients. No significant difference in the incidence of HFA between the 34 patients with chronic liver disease and the 19 patients with normal livers was found. One treated patient with an HFA and a history of gastrectomy developed a supraumbilical red skin rash. CONCLUSION: The angiographic incidence of the HFA is more common than previously reported. The delayed and persistent opacification of the HFA on hepatic angiograms caused by its slow blood flow is considered the key to its identification.

Treatment of deep vein thrombosis using temporary vena caval filters after allogeneic bone marrow transplantation.

Bone marrow transplant (BMT) recipients have risk factors for deep vein thrombosis (DVT) including venous stasis caused by immobilization in the sterile unit, vessel wall damage caused by preparative regimen or indwelling catheters, and hypercoagulability caused by decreased natural anticoagulants. We successfully treated a patient who developed massive DVT in the superior vena cava after BMT with anticoagulation and the use of temporary vena caval filters. Considering the delayed complications, permanent filter is not appropriate for BMT recipients, because the risk factors for DVT associated with BMT are transient. We considered that temporary vena caval filter is a safe and useful device to prevent pulmonary embolism after DVT in BMT recipients.

Kimura's disease with bilateral auricular masses.

We report an unusual case of Kimura's disease. An 81-year-old Japanese woman was shown to have bilateral auricular masses that had begun to enlarge 6 years before. On CT scans, slightly high-density masses with faint contrast enhancement were seen. The masses were heterogeneous and hypointense on T1-weighted MR images, were slightly hyperintense on T2-weighted MR images, and showed heterogeneous enhancement after the administration of contrast material. Kimura's disease should be included in the differential diagnosis of bilateral auricular tumors.

Helicobacter pylori of the remnant stomach and its eradication.

BACKGROUND/AIMS: Many authors have reported that Helicobacter pylori (H. pylori) is one of the major causes of gastritis and peptic ulcer. This study was conducted to evaluate the incidence of H. pylori infection and the curative effects of amoxicillin and omeprazole on H. pylori in the remnant stomach. METHODOLOGY: Biopsy specimens were obtained from 70 patients who underwent gastrectomy for gastric cancer. H. pylori was subsequently diagnosed by CLO test and culture of H. pylori. Gastritis was assessed by the scoring of four characteristic pathological parameters. Patients with positive H. pylori were eligible for the eradication study. Amoxicillin, 750 mg per day for 2 weeks, and omeprazole, 20 mg per day for 8 weeks, were administered to them. Endoscopic reexamination was performed 12 weeks after the initiation of treatment. RESULTS: The overall positive rate of H. pylori was 37.1%; 39.6% in Billroth I reconstruction, 0% in Billroth II reconstruction, and 55.6% in pylorus preserving gastrectomy, respectively. The positive H. pylori rate of Billroth II reconstruction was significantly low. However, there was no association of positive rate of H. pylori with time. There was no significant difference of gastritis scores between H. pylori infected patients and non-infected patients. The eradication rate was 70.0%. CONCLUSIONS: H. pylori was present in 37.1% of patients who underwent gastrectomy. Gastritis was not significantly severe in H. pylori infected patients. The treatment with amoxicillin and omeprazole was effective for these patients.

Intracranial aneurysms: detection with three-dimensional CT angiography with volume rendering--comparison with conventional angiographic and surgical findings.

PURPOSE: To assess the diagnostic accuracy of three-dimensional (3D) computed tomographic (CT) angiography for intracranial aneurysms. MATERIALS AND METHODS: The 3D CT angiograms obtained in 49 patients with or without intracranial aneurysms were evaluated by four blinded observers. Results were compared with findings at conventional angiography or surgery. A volume-rendering method was used, and 13 images obtained in different directions were reviewed in each study. The diameter of aneurysms was divided into four sizes: large, greater than 13 mm; medium, 5-12 mm; small, 3-4 mm; and very small, less than 3 mm. Results were also evaluated by means of receiver operating characteristic analysis. RESULTS: At conventional angiography, 47 aneurysms, including 14 less than 3 mm, were depicted in 35 patients. The mean sensitivity of CT angiography for very small aneurysms was 64%; small, 83%; medium, 95%; and large, 100%. Some very small aneurysms that were not depicted at conventional angiography were depicted at CT angiography, and one was proved at surgery. CONCLUSION: CT angiography has good sensitivity for depiction of intracranial aneurysms 3 mm or larger and relatively good sensitivity for aneurysms less than 3 mm. CT angiography may be a noninvasive technique for detection of asymptomatic unruptured or ruptured aneurysms.

Development of synchronous bilateral lung cancers after esophagectomy for esophageal cancer: report of a case.

It is well known that squamous cell carcinoma of the esophagus can be associated with carcinoma of other organs. We report herein the rare case of a 60-year-old man who developed synchronous bilateral lung cancers after undergoing esophagectomy for esophageal cancer. Staged bilateral lobectomy was successfully performed to minimize respiratory complications 3 years after his esophagectomy. This case report serves to demonstrate that aggressive and careful surgical approach with adequate followup offers the chance of long-term survival for patients with multiple primary cancers.

MRI and MR angiography in moyamoya disease.

The role of radiological imaging in moyamoya disease includes screening of the disease based on clinical findings, evaluation of the changes in vasculature and brain parenchyma, and clinical follow-up. The imaging findings in moyamoya disease are classified as primary and secondary. The primary findings essentially consist of occlusion of the circle of Willis and collateral formation, including moyamoya vessel formation. The secondary findings include cerebral infarction, white matter lesions, atrophy, and hemorrhage. For the visualization of the primary and secondary findings as well as postoperative results, MRI and MR angiography are the most reliable methods and play important roles because of their excellent diagnostic yield and noninvasiveness.

Intracranial penetrating injuries via the optic canal.

Two cases of intracranial penetration of a plastic or wooden chopstick via the optic canal are described. CT scans showed the chopsticks as linear hypodense structures in the suprasellar cistern contiguous with the optic canal. In one case, MR imaging was performed, which clearly depicted the foreign body and adjacent brain structures. Although they are extremely rare, transorbital intracranial penetrating injuries via the optic canal require physicians' awareness.

[Efficacy of the fluid attenuated inversion recovery (FLAIR) sequence of MRI as a preoperative diagnosis of hippocampal sclerosis].

A newly advanced MRI pulse sequence, the FLAIR (fluid attenuated inversion recovery) imaging, in which a long TE spin echo sequence is used with suppression of the CSF with an inversion pulse, displays the CSF space as a no-signal intensity area. There have been only a few reports on the FLAIR pulse sequence of temporal lobe epilepsy (TLE) as yet. We examined 9 cases of intractable TLE by FLAIR images and analyzed the advantages and disadvantages of the FLAIR pulse sequence for decision making on temporal lobectomy. All patients underwent anterior temporal lobectomy with hippocampectomy, and the diagnoses were confirmed histologically after surgery. Abnormally high T2 signals (HT2S) were more conspicuous with the FLAIR sequence than with any of the conventional sequences. Tilted axial plane, orientated along to the long axis of the hippocampal body, clearly demonstrated hippocampal atrophy (HA). Selection of a FLAIR sequence into the routine MR examination of patients with TLE is recommended.

Carcinosarcoma of the esophagus: three cases with immunohistological examination.

Carcinosarcoma of the esophagus is a rare malignant tumor with both carcinomatous and sarcomatous components. We present 3 cases of carcinosarcoma of the esophagus and discuss the histogenesis of the tumors. We performed immunohistochemical studies using various antibodies: anti-cytokeratin, anti-vimentin, anti-smooth muscle actin, anti-p53, and MIB 1 reacting with Ki-67 nuclear antigen.

Surgical techniques and the results of a fronto-temporo-parietal combined indirect bypass procedure for children with moyamoya disease: a comparison with the results of encephalo-duro-arterio-synangiosis alone.

We recently treated children with Moyamoya disease using a fronto-temporo-parietal combined indirect bypass procedure. Three different indirect bypass procedures (frontal EMAS, EDAS, EMS) were simultaneously carried out at three different sites. We thus treated 16 sides in 12 pediatric patients with Moyamoya disease using this method. Both the collateral formation and the improvement in the clinical symptoms were evaluated postoperatively. These results were then compared with those of the patients treated by EDAS alone. The postoperative collateral formation was more extensively seen in the patients treated with the combined bypass procedure than in those treated by EDAS alone. The improvement in ischemic symptoms was also better in the patients treated by the combined indirect bypass procedure. We therefore conclude that the combined indirect bypass procedure is more effective than EDAS alone.

Dural non-cavernous sinus arteriovenous fistulas symptomatically simulating spontaneous carotid-cavernous fistulas: an analysis of angiographic findings.

The sites of fistulas and patterns of venous drainage in 34 consecutive cases of dural AVFs manifesting symptoms suggesting CCFs were retrospectively analyzed to determine the frequency of dural AVFs in sites other than the cavernous sinus and to ascertain their causative mechanisms. In five cases (15%), dural AVFs were demonstrated in sites other than the cavernous sinus. Among four, retrograde venous flow due to occlusion of the outflow tract or a rapid-flow shunt resulted in filling of the superior ophthalmic vein. A rapid-flow dural AVF in the anterior cranial fossa showed no occlusive changes in the sinuses, and increased pressure in the cavernous sinus was thought to be responsible for the symptoms. Embolization was effective for relief of the symptoms. Symptoms mimicking CCFs can be seen in dural AVFs in sites other than the cavernous sinus with retrograde venous drainage or with a rapid-flow shunt, conditions which are not as rare as previously believed.

Increased activity of the ipsilateral motor cortex during a hand motor task in patients with brain tumor and paresis.

PURPOSE: To look for changes in the motor cortex in patients with brain tumors. METHODS: Both cerebral hemispheres in seven patients with brain tumors were examined with functional MR imaging during a motor task performed by the hand opposite the site of tumor. The ratio of the activated area in the motor cortex ipsilateral/contralateral to the tested hand was calculated for each subject. Twenty healthy subjects were also examined in the same manner for comparison. RESULTS: The ratio of the ipsilateral/contralateral activated area was abnormally high in three patients with tumor-related paresis of the tested hand. The ratio was significantly greater in patients with paresis than in healthy subjects. CONCLUSION: This study demonstrated increased activity in the ipsilateral (unaffected) motor area during a hand motor task in patients with brain tumor and paresis, which was thought to reflect compensatory reorganization induced by the functional damage.

Western versus Asian types of multiple sclerosis: immunogenetically and clinically distinct disorders.

The polymorphism of HLA-DRB1, -DRB3, and -DRB5 genes as well as magnetic resonance images of the brain and spinal cord were studied in 57 Japanese patients with multiple sclerosis (MS). Twenty-three patients clinically displayed selective involvement of the optic nerve and spinal cord and were classified as having Asian-type MS. The other 34 patients had disseminated central nervous system involvement and were classified as having Western-type MS. Patients with Asian-type MS had fewer brain lesions shown by magnetic resonance imaging, but more gadolinium-enhanced spinal cord lesions than did patients with Western-type MS (47% vs 17%). Furthermore, the DR2-associated DRB1*1501 allele and DRB5*0101 allele were associated with Western-type MS (41.2%), but not with either Asian-type MS (0%) or healthy control subjects (14.2%). Heterogeneity in the immunogenetic background and in the magnetic resonance imaging features between the two subtypes of MS thus suggests the presence of two etiologically distinct diseases in Asians.