Whole-body computed tomography as first-line imaging procedure to exclude cancer in patients with neurological suspicion of paraneoplastic syndromes: shall clinical practice adhere to recommendations?

INTRODUCTION: To assess the efficacy of whole-body computed tomography (WB-CT) as imaging procedure to exclude cancer in patients with neurological symptoms and signs at clinical onset. METHODS: A retrospective observational study was designed to identify consecutive WB-CT requested by the Neurology Unit with a suspicion of an underlying tumor potentially linked to a paraneoplastic neurological syndrome (PNS) between January 2019 and February 2022. The following data were collected: diagnosis at admission and at discharge, the presence of onconeural antibodies, the scans dose length product (DLP), the estimated effective dose (ED), the total estimated time requested; the PNS-Care-Score was retrospectively calculated only in subjects with available antibodies. RESULTS: The total number of patients included was 158. In 13/158 (positive group) a malignant or locally aggressive neoplasm was found while in 145/158 no malignant lesions were found on the WB-CT. Among the positive group, in 7/13 onconeural antibodies were diagnosed, resulting negative in all cases and the most frequent tumor was lung cancer (30.8%). PNS-Care-Score was of 6-7 in 2/7 (probable PNS) and in no case the PNS-Care-Score was ≥8 (definite PNS). The mean DLP for all the scans was 2798 ± 952 mGy cm (average estimated ED of 42 ± 14 mSv). The total estimated time requested for all scans was 11,060 min. CONCLUSION: If a PNS is suspected, we encourage the prescription of unenhanced chest CT and/or abdomen/testis/female pelvis ultrasound and/or mammography based on clinical picture. The WB-CT using a single portal phase would be appropriate as a second-line technique while magnetic resonance imaging might be indicated for the exclusion of nervous system diseases. IMPLICATIONS FOR PRACTICE: Our suggestion results in saving in terms of radiation exposure, financial resources and time.

Inward versus reward: white matter pathways in extraversion.

The trait of extraversion is one of the longest-standing domains that captures the social dimension of personality and can potentially explain the covariation of a wide variety of behaviors. To date, there is a growing recognition that human behavior should be specified not only through the psychological mechanisms underlying each trait but also through their underlying neurobehavioral systems. While imaging studies have revealed important initial insights into the structural and functional neural correlates of extraversion, current knowledge about the relationships between extraversion and brain structures is still rather limited, especially with regard to the relationship between extraversion and white matter (WM). In this study, we aimed to investigate WM microstructure in extraversion in greater depth. Thirty-five healthy volunteers (21 women; mean age 35) underwent magnetic resonance imaging, as a part of a larger project aimed at investigating the longitudinal effect of motor training. WM integrity was assessed using the diffusion tensor imaging technique combining multiple diffusion tensor measures. Extraversion was assessed by the Eysenck Personality Questionnaire-Revised. Voxelwise correlation analyses between fractional anisotropy, axial diffusivities, and radial diffusivities maps and extraversion score showed decreased connectivity in the right inferior fronto-occipital fasciculus and forceps major among individuals who had high extraversion ratings. In conclusion, individual differences in extraversion may reflect differential organization of the WM tracts connecting frontal cortex, temporal, and occipital areas, which are related to socioemotional and control functions.

Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.

A reddish pulsatile mass beyond tympanic membrane: think before act.

We report a case of a 76-year-old man that referred to our hospital because of progressive mixed right hearing loss, aural fullness and pulsatile tinnitus synchronized with heart beats. Otoscopic examination revealed a reddish pulsatile mass beyond tympanic membrane. CT and MRI scans showed a class C glomus tumor. Anamnesis and a complete physical examination, with careful differential diagnosis, should be obtained to rule out highly vascularized middle ear lesion before any invasive procedure.

Interventional Radiologist's perspective on the management of bone metastatic disease.

Bone metastases can be treated by interventional radiologists with a minimally invasive approach. Such treatments are performed percutaneously under radiological imaging guidance. Different interventional techniques can be applied with curative or palliative intent depending on lesions and patients' status. In the whole, available interventional techniques are distinguished into "ablative" and "consolidative". Ablative techniques achieve bone tumor necrosis by dramatically increasing or decreasing intra-tumoral temperature. This option can be performed in order to alleviate pain or to eradicate the lesion. On the other hand, consolidative techniques aim at obtaining bone defect reinforcement mainly to alleviate pain and prevent pathological fractures. We herein present evidence supporting the application of each different interventional technique, as well as common strategies followed by interventional radiologists while approaching bone metastases.

Lumbar subcutaneous edema and degenerative spinal disease in patients with low back pain: a retrospective MRI study.

PURPOSE: This study was designed to determine the association between LSE, spondylolisthesis, facet arthropathy, lumbar canal stenosis, BMI, radiculopathy and bone marrow edema at conventional lumbar spine MR imaging. METHODS: This is a retrospective radiological study; 441 consecutive patients with low back pain (224 men and 217 women; mean age 57.3 years; mean BMI 26) underwent conventional lumbar MRI using a 1.5-T magnet (Avanto, Siemens). Lumbar MR images were reviewed by consensus for the presence of LSE, spondylolisthesis, facet arthropathy, lumbar canal stenosis, radiculopathy and bone marrow edema. Descriptive statistics and association studies were conducted using STATA software 11.0. Association studies have been performed using linear univariate regression analysis and multivariate regression analysis, considering LSE as response variable. RESULTS: The overall prevalence of LSE was 40%; spondylolisthesis (p = 0.01), facet arthropathy (p < 0.001), BMI (p = 0.008) and lumbar canal stenosis (p < 0.001) were included in the multivariate regression model, whereas bone marrow edema, radiculopathy and age were not. CONCLUSIONS: LSE is highly associated with spondylolisthesis, facet arthropathy and BMI, suggesting underestimation of its clinical impact as an integral component in chronic lumbar back pain. Longitudinal simultaneous X-ray/MRI studies should be conducted to test the relationship of LSE with lumbar spinal instability and low back pain.

Perilimphatic fistula test: a video clip demonstration.

Perilymphatic fistula (PLF) is an abnormal condition in which a communication is present between the perilymphatic space of the inner ear and the middle ear or mastoid, secondary to a dehiscence in the otic capsule, oval or round window. LF may induce hearing loss, tinnitus, aural fullness, vertigo, disequilibrium, or a combination of these symptoms; the vagueness of symptoms caused by PLF and the lack of specificity of clinical signs and symptoms make the diagnosis elusive. We report a video of a positive PLF test induced by the application of pressure on the tragus, just anterior to the left external auditory canal in a patient with cholesteatoma and PLF of lateral semicircular canal confirmed by CT scan imaging. https://www.youtube.com/watch?v=x5MhSILF9O4.

Dynamic contrast-enhanced MR evaluation of prostate cancer before and after endorectal high-intensity focused ultrasound.

PURPOSE: The authors sought to determine the diagnostic performance of dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging in the evaluation of prostate cancer before and after transrectal high-intensity focused ultrasound (HIFU) treatment. MATERIALS AND METHODS: We analysed 25 patients with prostate cancer. The prostate-specific antigen (PSA) value was evaluated 1, 4 and 6 months after treatment. DCE-MR imaging was performed the day prior to and 1, 4 and 6 months after HIFU treatment. Transrectal prostate biopsies were obtained at the time of diagnosis and 6 months after treatment. RESULTS: Before treatment, intraglandular lesions were considered to be potential sites of neoplasm and subsequently confirmed as sites of prostate adenocarcinoma in all 25 patients based on prostatespecific antigen (PSA) values and histological examinations (rho=1; p<0.001). Using histology as the gold standard, DCE-MR imaging displayed 100% sensitivity, 100% specificity, 100% positive predictive value and 100% negative predictive value before treatment. After HIFU treatment, DCE-MR imaging showed 100% sensitivity and 96% specificity. CONCLUSIONS: DCE-MR imaging can be used to visualise prostate adenocarcinoma. Several morphological and postgadolinium modifications in the follow-up DCE-MR images after HIFU treatment were also observed.

Upper airway study should always come before any sleep study in OSAS evaluation: a giant parapharyngeal lipoma behind OSAS.

BACKGROUND: The parapharyngeal space (PPS) is a rare site for neoplasms in the head and neck and lipoma represents 0.5% of all head and neck tumors. CASE REPORT: We describe a case of a giant parapharyngeal lipoma in obese adult patient causing anatomic pharyngeal obstruction with severe obstructive sleep apnea (OSA) syndrome. The patient was successfully operated with transcervical approach. CONCLUSIONS: In patients presenting with symptoms suggestive of OSA, it is essential to rule out any physical cause and perform a comprehensive ear, nose and throat examination including fibro-endoscopic upper airway examination before referral for sleep study and management. The ideal management for OSA involves treating the underlying cause. If no definitive cause is identified, management should begin with conservative measures such as lifestyle changes and a weight loss program; if these are unsuccessful, continuous positive airway pressure (CPAP), oral appliances or upper airway surgery could be considered. Better diagnostic methods should be developed to identify the main OSA causes and improve therapeutic outcomes.

Central nervous system tuberculosis in non-HIV-positive children: a single-center, 6 year experience.

PURPOSE: The aim of this paper is to describe the imaging features of central nervous system (CNS) tuberculosis on computed tomography (CT) and magnetic resonance imaging (MRI) studies in non-HIV-positive children. MATERIALS AND METHODS: A retrospective descriptive evaluation was conducted on imaging studies obtained from ten children admitted to our hospital over a 6-year period who fulfilled criteria for a diagnosis of CNS tuberculosis. Data were collected with regard to patients' clinical, laboratory and demographic characteristics, as well as results of radiological investigation. RESULTS: We studied ten children, of whom five were boys and five were girls and whose mean age was 4 (range 7 months to 16) years. Neuroradiological findings on the first imaging study were basal meningeal enhancement (100%), hydrocephalus (70%), infarcts (90%), tuberculomas (40%) and cranial nerve involvement (20%). Follow-up studies revealed basal meningeal enhancement, hydrocephalus, and infarcts in all patients, tuberculomas in 70% and cranial nerve involvement in 50%. Only one patient showed a pattern of miliary tuberculosis. CONCLUSIONS: CNS tuberculosis is still an important cause of childhood morbidity and mortality even in nonimmunosuppressed children. Because prompt diagnosis results in earlier treatment, it is crucial to be aware of tuberculous meningitis and its complications at imaging, especially because of the impact on patients' prognosis.

Meningeal involvement in Wegener granulomatosis: case report and review of the literature.

Wegener Granulomatosis (WG) is a multisystem autoimmune disorder characterized by necrotizing granulomatous vasculitis that most commonly involves the upper respiratory tract, lungs, and kidneys. The involvement of the central nervous system (CNS) is infrequent and can cause stroke, cranial nerve abnormalities, cerebrovascular events, seizures, and meningeal involvement. Meningeal involvement is rare and may occur due to local vasculitis, directly spread from adjacent disease in the skull base, paranasal or orbital region. We describe the case of a 20-year-old Caucasian man who was diagnosed with sinonasal WG with frontal focal meningeal involvement. A literature review on diagnosis and treatment of meningeal involvement in course of WG was carried out. The importance of an early diagnosis and treatment of localized WG has been emphasized, in order to avoid the progression to a severe form of disease, especially in younger patients and in paucisymptomatic cases.

Modic changes: anatomy, pathophysiology and clinical correlation.

Studying discovertebral complex anatomy is extremely important for the understanding of the pathophysiology of disc degeneration which leads to vertebral endplates signal changes, also known as Modic changes.The sequelae of disc degeneration are among the leading causes of functional incapacity in both sexes and are one of the most common sources of chronic disability in the working years. Even if the presence of degenerative changes in MRI of the spine is by no means an indicator of symptoms, we are concordant in a positive association between Modic changes and low back pain, above all as a relatively specific but insensitive sign of discogenic low back pain.

Differentiation of normal and neoplastic bone tissue in dynamic gadolinium-enhanced magnetic resonance imaging: validation of a semiautomated technique.

PURPOSE: This study was undertaken to clinically validate the accuracy of a semiautomated software tool for analysing the enhancement curve in focal malignant bone lesions. MATERIALS AND METHODS: Twenty-three patients affected by cancer with malignant focal bone lesions underwent dynamic gadolinium-enhanced magnetic resonance (MR) imaging using the following protocol: T1-weighted turbo spin-echo sequences (time to repeat [TR] 600 ms, time to echo [TE] 8.6 ms, field of view [FOV] 40x40 cm) before and after intravenous injection of gadolinium-containing contrast agent. Image postprocessing was performed using the software DyCoH. Each region of interest (5x5 pixels), drawn to include the area of the lesion with the highest values of the area under the curve map, was analysed to obtain time-intensity curves and relative perfusion parameters: time to peak (TTP), peak intensity (PI), slope (60-s slope), intensity at 60 s after contrast agent injection (60-s I) and final intensity (FI). RESULTS: Data were obtained by analysing 86 malignant lesions and 86 apparently normal bone regions. PI, 60-s slope, 60-s I and FI were significantly different between neoplastic and apparently normal (p<0.001) samples. Sensitivity, specificity and accuracy were, respectively, 94%, 93% and 94% at a PI threshold of 100 (signal-to-noise ratio), with positive and negative predictive values of 93% and 94%. At a threshold value of 0.85 for 60-s slope, sensitivity and specificity values were both 91%. CONCLUSIONS: The semiautomated technique we report appears to be accurate for identifying neoplastic tissue and for mapping perfusion parameters, with the added value of a consistent measurement of perfusion parameters on colour-coded maps.

Incidence of new fractures in women with osteoporosis-induced vertebral fractures detected on routine lateral chest radiographs.

PURPOSE: Vertebral fractures represent one of the major complications of osteopororis. Diagnosis is followed by a pharmacological, interventional or surgical treatment. Up to day there are non practice guidelines for a screening evaluation of bone fractures in elderly and most of the fractures remain undiagnosed. We prospectively evaluated the prevalence of vertebral fractures on chest X-rays to determine the diagnostic and prognostic roles of chest X-ray in predicting new bone fractures 2 years after the initial radiogram. MATERIALS AND METHODS: Between March 2004 and October 2005, 4,045 women underwent chest X-ray in our radiology department for any indication. We identified 166 women with the presence of at least one vertebral fracture. A questionnaire was administered to these women to collect information about diagnosis of osteoporosis, history of malignancy, systemic diseases, osteoporosis-inducing drugs and pharmacological, radiological or surgical treatment received. RESULTS: Out of the 166 women (age 73+/-10.5 years) with vertebral fractures, we interviewed 101 women; 13 had died and 52 were not found. Most of the patients were on menopause (97.1%, 98/101) with an average age of menopause of 48,2 years (+/-6 years). Among the patients on menopause, 15,8% (16/101) had undergone hysterectomy. All patients received a diagnosis of osteoporosis, which was reached with a chest X-ray report in 23.7% (24/101) of cases. A new skeletal fracture occurred in 20.5% (5/27) of patients receiving treatment against a frequency of 20.8% (16/74) in patients without treatment. No statistical difference was found between the groups (p = 0.374). CONCLUSIONS: Inadequate treatment may explain the lack of a substantial difference in new fracture risk between treated and untreated patients. For these reason we discuss about the evaluation of an adeguate therapeutic approaches in prevention of osteoporosis-induced fractures.

Dorsal brain stem syndrome: MR imaging location of brain stem tegmental lesions in neonates with oral motor dysfunction.

The anatomic extent of brain stem damage may provide information about clinical outcome and prognosis in children with hypoxic-ischemic encephalopathy and oral motor dysfunction. The aim of this study was to retrospectively characterize the location and extent of brain stem lesions in children with oral motor dysfunction. From January 2005 to August 2009, 43 infants hospitalized at our institution were included in the study because of a history of hypoxic-ischemic events. Of this group, 14 patients showed oral motor dysfunction and brain stem tegmental lesions detected at MR imaging. MR imaging showed hypoxic-ischemic lesions in supra- and infratentorial areas. Six of 14 patients revealed only infratentorial lesions. Focal symmetric lesions of the tegmental brain stem were always present. The lesions appeared hyperintense on T2-weighted images and hypointense on IR images. We found a strong association (P < .0001) between oral motor dysfunction and infratentorial lesions on MR imaging. Oral motor dysfunction was associated with brain stem tegmental lesions in posthypoxic-ischemic infants. The MR imaging examination should be directed to the brain stem, especially when a condition of prolonged gavage feeding is necessary in infants.

Infratentorial lesion volume correlates with sensory functional system in multiple sclerosis patients: a 3.0-Tesla MRI study.

PURPOSE: This study sought to correlate lesion volume in infratentorial areas using 3.0-T proton-density (PD)-weighted images with disability scales and appropriate functional system scores in patients with multiple sclerosis (MS). MATERIALS AND METHODS: We examined 20 consecutive patients (13 women and 7 men) with a median age of 47 years (range 26-70). Neurological examination included the Expanded Disability Status Scale and its functional systems, the Barthel Index (BI) and the Rivermead Mobility Index (RMI). MRI scans were performed on a system operating at 3.0 T using a quadrature birdcage head coil. Acquired images imported as Digital Imaging and Communication in Medicine (DICOM) files, and the region of interest (ROI) files were converted to Neuroimaging Informatics Technology Initiative (NIfTI) format and normalised to the Montreal Neurological Institute (MNI) standard template. An automated segmentation algorithm was used to distinguish between supratentorial and infratentorial areas. Normalisation to the magnetisation-prepared rapid acquisition with gradient echo (MPRAGE) T1-weighted sequence allowed lesion volume estimation in the different anatomical areas. RESULTS: A significant correlation was found between infratentorial lesion volume and the sensory functional system score (rho=0.76, p=0.002). No significant correlation was found between supratentorial lesion volume and Expanded Disability Status Scale (EDSS), RMI and BI scores. CONCLUSIONS: The described method, by means of anatomical assignment of MS lesions, allows detection of significant correlation coefficients between clinical and MRI lesion burden in MS patients at the infratentorial level.

Bone metastases in breast cancer: higher prevalence of osteosclerotic lesions.

PURPOSE: It is well known that bone metastases from breast cancer usually show osteolytic changes. We retrospectively analysed the computed tomography (CT) appearance of bone metastases to quantify the distribution of lytic, mixed and sclerotic changes in a series of patients presenting with neoplastic bone involvement from breast cancer. MATERIALS AND METHODS: Between 1996 and 2005, 468 women with a diagnosis of breast cancer were referred to our department for staging or follow-up CT examinations. Staging CT examinations detected systemic metastases in 142/468 patients, 60 of which had bone involvement. Patients with a second primary tumour or bone metabolic disorders were excluded from this retrospective analysis. RESULTS: In patients with bone metastases, CT identified 18 with osteolytic lesions (30%), 32 with osteosclerotic lesions (53.3%) and ten with mixed lesions (16.7%). Analysis of the cases observed for the first time during the 1996-2000 period showed osteolytic lesions in 53.6% (15/28), osteosclerotic lesions in 32.1% (9/28) and mixed lesions in 14.3% (4/28). Results were 9.4% (3/32), 71.9% (23/32) and 18.7% (6/32), respectively, for the same groups in the 2001-2005 period. Histological analysis of all cases included 81.9% of infiltrative ductal carcinoma, 11.2% of infiltrative lobular carcinoma, 3.7% of ductal lobular mixed carcinoma and 3% of medullar carcinoma. We found no statistically significant correlation between histological type of breast cancer and radiological appearance of bone metastasis. A significant difference between patients treated with or without zoledronic acid was observed, with a higher prevalence of osteosclerotic lesions in the former group of patients (p<0.05). CONCLUSIONS: We observed an increasing prevalence of osteosclerotic bone metastasis when comparing the 1996-2000 period with the 2001-2005 period. The significance of these distribution changes is not clear. However, we found a significant correlation of osteosclerotic lesions with zoledronic acid treatment. The advent of third generation bisphosphonates may have changed the CT appearance of bone metastasis from breast cancer.