Continuous PENG block in an oncologic patient with bilateral femoral avascular necrosis.

The PENG block (pericapsular nerve group) is a recently described technique to address the innervation of the hip, one of the most complex anatomical regions to treat at the locoregional level. We present the case of a patient with acute lymphoblastic leukaemia complicated by avascular necrosis of the bilateral femoral head and previous history of severe chronic pain with probable central sensitization to opioids and a severe thrombocytopenia due to myelotoxicity from chemotherapy treatment. Given the need for orthopaedic surgery to manage femoral necrosis and in anticipation of complex perioperative pain management, a multimodal strategy was planned including bilateral ultrasound-guided continuous PENG blocks to achieve proper pain control in the perioperative period and promote early recovery. The operation and initial recovery were uneventful and the patient was discharged to the ward within 24 h and started early rehabilitation as planned. The patient had a successful recovery with good functionality.

Técnica de radiofrecuencia pulsada en síndrome de ACNES invalidante en una paciente pediátrica / Pulsed radiofrequency in a paediatric patient with disabling ACNES

El dolor abdominal crónico es una entidad muy prevalente en la población pediátrica y supone todo un reto diagnóstico para los profesionales, siendo frecuentemente infradiagnosticada. Requiere un abordaje multidisciplinar y una minuciosa evaluación clínica para descartar otras enfermedades. El ACNES consiste en un atrapamiento de los nervios cutáneos anteriores de los nervios intercostales y origina un dolor abdominal intenso, unilateral, circunscrito y frecuentemente presenta un Pinch test y un test de Carnett positivos. El planteamiento terapéutico debería contemplarse desde un enfoque gradual, reservando las técnicas más invasivas para los pacientes con ACNES refractario. Entre los múltiples tratamientos posibles las infiltraciones locales presentan una alta tasa de éxito, reservando las técnicas quirúrgicas para los casos refractarios. Presentamos el caso clínico de una niña de 11 años, con ACNES de 6 meses de evolución, con grave afectación de su calidad de vida y con respuesta favorable a la técnica de radiofrecuencia pulsada.(AU)

Chronic abdominal pain is a highly prevalent entity in the paediatric population and represents a diagnostic challenge for professionals. It is frequently underdiagnosed, and must be treated by a multidisciplinary team after a detailed clinical evaluation has been performed to rule out other pathologies. Anterior cutaneous nerve entrapment syndrome (ACNES) occurs when the anterior cutaneous abdominal nerves become pinched or trapped, causing intense, unilateral, circumscribed abdominal pain. Patients often present a positive Pinch test or Carnett's sign. A stepwise therapeutic approach should be used, reserving the most invasive techniques for patients with refractory ACNES. Among the many different treatments available, local anaesthesia infiltration has shown a high success rate, and surgery should only be performed in the most refractory cases. We report the case of an 11-year old girl with a 6-month history of ACNES that severely affected her quality of life, who responded well to pulsed radiofrequency ablation.(AU)

Pulsed radiofrequency in a paediatric patient with disabling ACNES.

Chronic abdominal pain is a highly prevalent entity in the paediatric population and represents a diagnostic challenge for professionals. It is frequently underdiagnosed, and must be treated by a multidisciplinary team after a detailed clinical evaluation has been performed to rule out other pathologies. Anterior cutaneous nerve entrapment syndrome (ACNES) occurs when the anterior cutaneous abdominal nerves become pinched or trapped, causing intense, unilateral, circumscribed abdominal pain. Patients often present a positive Pinch test or Carnett's sign. A stepwise therapeutic approach should be used, reserving the most invasive techniques for patients with refractory ACNES. Among the many different treatments available, local anaesthesia infiltration has shown a high success rate, and surgery should only be performed in the most refractory cases. We report the case of an 11-year old girl with a 6-month history of ACNES that severely affected her quality of life, who responded well to pulsed radiofrequency ablation.

Longitudinal changes in brain morphology from 4 weeks to 12 months after mild traumatic brain injury: Associations with cognitive functions and clinical variables.

OBJECTIVE: To investigate longitudinal changes in cortical and subcortical volumes in patients with mild traumatic brain injury (MTBI) and to evaluate whether such changes were associated with self-reported post-concussive symptoms, global functional outcomes and neuropsychological functioning. METHODS: This was a prospecitve, longitudinal cohort study of patients with complicated (i.e presence of intracranial abnormalities on the day of injury CT) and uncomplicated MTBI (i.e, absence of intracranial abnormalities). Magnetic resonance imaging (MRI) was performed at approximately 4 weeks and 12 months. We utilized a 3T MRI system, cortical reconstruction and volumetric segmentation by FreeSurfer software. We included 33 patients with uncomplicated and 29 with complicated MTBI, who were aged 16-65 years. RESULTS: 12 months after MTBI, significant within-group volume reductions were detected in the left accumbens area and right caudate nucleus for both patients groups, but no significant differences between the groups were revealed. No associations between volumetric variables and post-concussive symptoms or global functioning were found. The left temporal thickness was significantly associated with executive functioning. CONCLUSION: Structural subcortical alterations occur after complicated and uncomplicated MTBIs but these findings were not associated with symptoms burden or functional outcomes. Nonetheless, worse executive functioning was found in patients with shrinkage of the left temporal lobe.

Volumetric and morphometric MRI findings in patients with mild traumatic brain injury.

OBJECTIVE: This study compared cortical and sub-cortical volumes between patients with complicated (i.e. presence of intracranial abnormality on the day-of-injury CT) and uncomplicated (i.e. absence of intracranial abnormality) mild traumatic brain injury (MTBI) 4 weeks post-injury. The study hypothesized regionally decreased brain volumes and reduced cortical thickness in patients with complicated MTBIs compared with uncomplicated MTBI. METHODS: This study was part of a larger 2 years cohort study on MTBI. Baseline clinical and magnetic resonance imaging (MRI) data were compared for those with complicated and uncomplicated MTBI. It identified 168 patients with MTBI (90 uncomplicated and 78 complicated), aged 16-65 years. 3T MRI-system (Signa HDxt, GE Medical Systems, Milwaukee, WI) and cortical reconstruction and volumetric segmentation by FreeSurfer software have been used. RESULTS: No significant differences between uncomplicated and complicated MTBIs were found in neuroanatomic volumes and cortical thickness after controlling for age, gender and education. The complicated MTBI group showed larger ventricles compared with the uncomplicated group, but this effect diluted when adjusting for potential confounders. CONCLUSION: The study findings suggest that the classification of complicated and uncomplicated MTBI may be too broad to differentiate volumetric and morphometric effects of injury in the early post-injury phase.

Genetic variants affecting the neural processing of human facial expressions: evidence using a genome-wide functional imaging approach.

Human faces present crucial visual information for social interaction. Specialized brain regions are involved in the perception of faces, with the fusiform face area (FFA) a key neuronal substrate. Face processing is genetically controlled, but by which specific genes is unknown. A genome-wide approach identified common single nucleotide polymorphisms (SNPs) associated with areas of increased brain activity in response to affective facial expressions, measured with functional magnetic resonance imaging. SNPs in 20 genetic regions were linked with neural responses to negative facial expressions in a Norwegian sample (n=246), which included patients with mental illness. Three genetic regions were linked with FFA activation in a further discovery experiment using positive facial expressions and involving many of the same individuals (n=284). Two of these three regions showed significant association with right FFA activation to negative facial expressions in an independent North American replication sample of healthy Caucasians (n=85, 3q26.31, P=0.004; 20p12.3, P=0.045). The activation patterns were particularly striking for the SNP in 3q26.31, which lies in a gene TMEM212; only the FFA was activated. The specialized function of this brain region suggests that TMEM212 could contribute to the innate architecture of face processing.

Quantitative apparent diffusion coefficients in the characterization of brain tumors and associated peritumoral edema.

BACKGROUND: Conventional magnetic resonance (MR) imaging has a number of limitations in the diagnosis of the most common intracranial brain tumors, including tumor specification and the detection of tumoral infiltration in regions of peritumoral edema. PURPOSE: To prospectively assess if diffusion-weighted MR imaging (DWI) could be used to differentiate between different types of brain tumors and to distinguish between peritumoral infiltration in high-grade gliomas, lymphomas, and pure vasogenic edema in metastases and meningiomas. MATERIAL AND METHODS: MR imaging and DWI was performed on 93 patients with newly diagnosed brain tumors: 59 patients had histologically verified high-grade gliomas (37 glioblastomas multiforme, 22 anaplastic astrocytomas), 23 patients had metastatic brain tumors, five patients had primary cerebral lymphomas, and six patients had meningiomas. Apparent diffusion coefficient (ADC) values of tumor (enhancing regions or the solid portion of tumor) and peritumoral edema, and ADC ratios (ADC of tumor or peritumoral edema to ADC of contralateral white matter, ADC of tumor to ADC of peritumoral edema) were compared with the histologic diagnosis. ADC values and ratios of high-grade gliomas, primary cerebral lymphomas, metastases, and meningiomas were compared by using ANOVA and multiple comparisons. Optimal thresholds of ADC values and ADC ratios for distinguishing high-grade gliomas from metastases were determined by receiver operating characteristic (ROC) curve analysis. RESULTS: Statistically significant differences were found for minimum and mean of ADC tumor and ADC tumor ratio values between metastases and high-grade gliomas when including only one factor at a time. Including a combination of in total four parameters (mean ADC tumor, and minimum, maximum and mean ADC tumor ratio) resulted in sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of 72.9, 82.6, 91.5, and 54.3% respectively. In the ROC curve analysis, the area under the curve of the combined four parameters was the largest (0.84), indicating a good test. CONCLUSION: Our results suggest that ADC values and ADC ratios (minimum and mean of ADC tumor and ADC tumor ratio) may be helpful in the differentiation of metastases from high-grade gliomas. It cannot distinguish high-grade gliomas from lymphomas, and lymphomas from metastases. ADC values and ADC ratios in peritumoral edema cannot be used to differentiate edema with infiltration of tumor cells from vasogenic edema when measurements for high-grade gliomas, lymphomas, metastases, and meningiomas were compared.

Calvarial lesions: a radiological approach to diagnosis.

Calvarial lesions are frequently identified in radiological studies. A wide variety of neoplasms and non-neoplastic lesions can involve the calvarium, and their imaging appearances vary according to their pathologic features. These lesions are usually asymptomatic but may manifest as a lump with or without associated pain. Clinical information, including the age of patient, is an important factor in the diagnostic process. In this paper, we illustrate the value of cross-sectional imaging techniques by computed tomography (CT) and magnetic resonance imaging (MRI) in evaluating these lesions. We also review the literature and discuss the specific imaging characteristics of the most common calvarial lesions in order to provide information that can guide radiological diagnosis or limit differential diagnosis.

Proton magnetic resonance spectroscopy and cognition in patients with spastin mutations.

The hereditary spastic paraplegias (HSP) are heterogeneous neurodegenerative disorders characterized by progressive spasticity and weakness in the lower limbs. Axonal loss in the long corticospinal tracts has been shown. Supraspinal symptoms and findings in the most common dominant HSP type, SPG4, support the theory that the disease also causes cerebral neuronal damage in specific parts of the brain. To investigate whether SPG4-HSP is associated with neuronal biochemical changes detectable on MR spectroscopy (MRS), single-voxel proton MRS of the brain was performed in eight subjects from four families with genetically confirmed SPG4-type HSP and eight healthy age-matched controls. Volumes of interest (VOI) were located in the frontal white matter and motor cortex. N-acetyl-aspartate-to-creatine ratio (NAA/Cr), N-acetyl-aspartate-to-choline (NAA/Cho), cholin to creatin (Cho/Cr) and myo-inositol-to-creatine (Ins/Cr) ratios were calculated for both locations. Neuropsychological tests were performed to support the neuroradiological findings. The Cho/Cr ratio in motor cortex (MC) of SPG4-HSP subjects was significantly lower than in controls. This reduction of the Cho/Cr ratio in SPG4 subjects was significantly associated with age-related verbal learning- and memory (CVLT) reduction. Our findings support involvement of motor cortex in SPG4-HSP. Proton MRS could be a useful tool for detecting metabolite abnormalities in areas of brain that appear normal on MRI. Cho/Cr ratio may be a marker of neurodegenerative process in SPG4-HSP.

The human amygdala is involved in general behavioral relevance detection: evidence from an event-related functional magnetic resonance imaging Go-NoGo task.

The amygdala is classically regarded as a detector of potential threat and as a critical component of the neural circuitry mediating conditioned fear responses. However, it has been reported that the human amygdala responds to multiple expressions of emotions as well as emotionally neutral stimuli of a novel, uncertain or ambiguous nature. Thus, it has been proposed that the function of the amygdala may be of a more general art, i.e. as a detector of behaviorally relevant stimuli [Sander D, Grafman J, Zalla T (2003) The human amygdala: an evolved system for relevance detection. Rev Neurosci 14:303-316]. To investigate this putative function of the amygdala, we used event related functional magnetic resonance imaging (fMRI) and a modified Go-NoGo task composed of behaviorally relevant and irrelevant letter and number stimuli. Analyses revealed bilateral amygdala activation in response to letter stimuli that were behaviorally relevant as compared with letters with less behavioral relevance. Similar results were obtained for relatively infrequent NoGo relevant stimuli as compared with more frequent Go stimuli. Our findings support a role for the human amygdala in general detection of behaviorally relevant stimuli.

Primary spinal chondrosarcoma: radiologic findings with pathologic correlation.

PURPOSE: To describe the radiologic appearance of the four types of primary spinal chondrosarcoma (CHS) (conventional intramedullary, juxtacortical, clear cell, and mesenchymal) and to correlate with histopathologic findings. MATERIAL AND METHODS: A retrospective review was carried out of 5 patients with histopathologically confirmed primary spinal CHS; 3 F and 2 M ranging in age between 27 and 66 years (mean 40.2; median 39). Charts, conventional radiographs, computed tomography scans, and magnetic resonance images were reviewed. All the patients underwent surgical excision, followed by postoperative chemotherapy (1 patient) and radiotherapy (3 patients). Follow-up was available for all patients but one. The mean follow-up was 42 months (14-120 months). Histopathological specimens for all patients were available for review. RESULTS: Vertebral column distribution was 3 thoracic (60%), 1 cervical (20%), and 1 lumbar (20%). Neurological deficits were present in 3 (60%) cases. The radiological appearance of the four types of primary spinal CHS varies with specific lesion type. Imaging findings suggest diagnosis of the conventional intramedullary and juxtacortical types. While the clear cell and mesenchymal types show some distinctive features, these do not allow confident radiologic diagnosis. CONCLUSION: The radiologist must be aware of imaging features of these tumors in order to improve diagnostic accuracy, treatment planning, and prognosis.

Traumatic cervical injuries in ankylosing spondylitis.

PURPOSE: To demonstrate the importance of magnetic resonance (MR) and computed tomography (CT) in the evaluation of cervical traumas in patients suffering from ankylosing spondylitis. MATERIAL AND METHODS: Eleven patients with advanced ankylosing spondylitis were admitted to neurosurgical treatment after trauma to the neck region. All had neurological symptoms and were evaluated with plain X-ray, CT, and MR. RESULTS: CT with reformation sagittal and coronal plane was superior to plain X-ray films in demonstrating fractures and dislocations. MR was considered mandatory when evaluating changes in medulla and epidural hematomas, which were detected in 4 patients. The clinical outcome was poor in 5 patients and good in 6. The poorest outcome was seen in patients with cord contusion and epidural hematoma. CONCLUSION: We conclude that plain X-ray is of no greater importance in the acute phase of highest value in follow-up evaluation of the healing process and final position of the fractured vertebrae. Our protocol in the acute phase in traumatized ankylopoetic patients consists of lateral conventional X-ray, CT with reformatted images, and MR, the last-mentioned being important in detecting epidural hematoma that reduces the clinical outcome further if not removed. In our opinion, MR must be part of the radiological protocol following neck traumas in all patients with ankylosing spondylitis.

Conventional and diffusion-weighted MRI in the evaluation of methanol poisoning.

Cerebral lesions were studied in 2 methanol-poisoned patients using conventional magnetic resonance imaging (MRI). In 1 patient, diffusion-weighted MRI (DWI) was also performed. In this patient, conventional MRI showed symmetrical, bilateral increased signal in the lentiform nuclei, involving predominantly putamina, but also extending into the corona radiata, centrum semiovale and subcortical white matter. DWI showed decreased diffusion, which most probably reflects cytotoxic edema. In the other patient, fluid attenuated-inversion recovery (FLAIR) and T2-weighted images showed hyperintensity in the putamina, characteristic of post-necrotic changes.

[Patient-rated wrist questionnaire: preliminary report on a proposed French version of a North American questionnaire designed to assess wrist pain and function]. / Auto-évaluation de la douleur et de la fonction du poignet. Proposition d'une version française d'un questionnaire nord-américain et essai préliminaire.

We present a French translation of a North American self-assessment questionnaire (Patient Rated Wrist Questionnaire or PRWE). This questionnaire was developed by Joy MacDermid and members of the IWI (International Wrist Investigators). Three years were needed to establish the specific items and questions to get a valid and reliable questionnaire. It includes 5 questions on pain and 10 questions on function. All the questions were rated on a 0-10 scale. The questionnaire provides several scoring options with a total of 100. MacDermid assessed the responsiveness of three questionnaires (DASH, SF-36 and PRWE) in 59 patients after distal radius fractures. Standardised response means (SRM) were calculated to indicate responsiveness. The PRWE was the most responsive. The French version was evaluated on 20 patients. All the questions were understood. The mean writing time was 5 minutes (3 min - 7 min).

MR imaging of ventriculus terminalis of the conus medullaris. A report of two operated patients and a review of the literature.

We report on 2 patients in whom a cystic dilation of the conus medullaris was incidentally found at MR imaging carried out in the work-up for sciatica. The cysts were well circumscribed and had signal intensity identical to the CSF on both T1- and T2-weighted images. There was no evidence of contrast enhancement. None of the patients had specific symptoms related to the spinal cord. At surgery, no evidence of malignancy was seen in any of the patients. A benign cystic dilation, also called dilated ventriculus terminalis, occasionally can be seen in the conus medullaris as an incidental finding at thoracolumbar MR imaging. Unless the expansion per se indicates cyst drainage, these patients may be monitored by clinical and MR follow-up, avoiding surgery in a substantial number of cases.

Vertex epidural hematoma - neuroradiological findings and management.

Epidural hematomas occurring at the vertex are uncommon, and they can be difficult to diagnose by axial CT. We report a case of acute traumatic vertex epidural hematoma, which resolved spontaneously with time. We stress the importance of MR investigations in this diagnostic challenge.

Post-traumatic cerebral infarction. Neuroimaging findings, etiology and outcome.

PURPOSE: To assess the radiological characteristics of post-traumatic cerebral infarctions (PTCIs), the etiology and site of infarction, and to provide neuroimaging indicators of a poor clinical outcome. MATERIAL AND METHODS: A retrospective study of 16 patients with the neuroimaging-based diagnosis of PTCI was carried out. All CT, MR examinations, cerebral angiograms and medical records of the patients were reviewed. RESULTS: Infarcts were diagnosed in the territory of the posterior cerebral artery in 9 patients, in the middle cerebral artery in 5, in the anterior cerebral artery in 3, lenticulostriate-thalamoperforating in 2, vertebrobasilar in 3, and cortical infarcts in 2 patients. Neuroimaging studies suggested focal mass effect and/or acquired intracranial herniations as the cause of infarction in 13/16 patients (81.2%). In 3/16 patients (18.8%), PTCI was due to vascular injury of which 2 were angiographically documented (carotid artery dissection). Eight of the 16 patients in this study died or were left in a persistent vegetative state. Patients with associated subdural hematoma, brain swelling/edema and traumatic subarachnoid hemorrhage (tSAH) exhibited the worst outcome. CONCLUSION: Gross mechanical shift of the brain and herniation across the falx and/or tentorium accounted for infarction in a majority of cases in our study. The overall death rate was 43.8% and this result suggests that PTCI is an indication of a poor clinical outcome, especially among patients with associated subdural hematoma, brain swelling/edema and tSAH.

Novel 1-phenylpiperazine and 4-phenylpiperidine derivatives as high-affinity sigma ligands.

sigma receptors may represent an exciting new approach for the development of novel psychotherapeutic agents. Unfortunately, many of the commonly used sigma ligands lack selectivity (e.g., many bind at phencyclidine or dopamine receptors) or suffer from other serious drawbacks. Recently, we described a series of 2-phenylaminoethanes that bind at sigma receptors with high affinity and selectivity. Because there is evidence that 1-phenylpiperazines can structurally mimic the 2-phenylaminoethane moiety, we prepared a series of 1-phenylpiperazines and related analogues and incorporated structural features already shown to enhance the sigma binding of the 2-phenylaminoethanes. Several of these derivatives bind at sigma receptors with high affinity (Ki = 1-10 nM) and lack appreciable affinity for phencyclidine and dopamine receptors. In as much as certain of these agents structurally resemble the high-affinity, but nonselective, sigma ligand haloperidol, and because they bind with 10 times the affinity of haloperidol, we have apparently identified what appears to be the primary sigma pharmacophore of that agent.

Binding of substituted and conformationally restricted derivatives of N-(3-phenyl-n-propyl)-1-phenyl-2-aminopropane at sigma-receptors.

Certain benzomorphans, such as N-allylnormetazocine, are classical "sigma-opiates" that bind both at sigma and phencyclidine (PCP) binding sites with modest affinity. Recently, we identified N-substituted 2-phenylaminoethane as being the primary sigma-pharmacophore of the benzomorphans and demonstrated that 1-phenyl-2-aminopropane (2) derivatives, depending upon their terminal amine substituents, constitute a novel class of high-affinity sigma-selective agents. With this pharmacophore, it is shown in the present investigation that the aromatic hydroxyl group (a prime feature of all the sigma-opiates) contributes little to the binding of 2 at sigma-sites. It is also demonstrated that an N-substituted aminotetralin moiety (such as 17, a conformationally restricted analogue of 2) may also be considered a sigma-opiate pharmacophore. Unlike the sigma-opiates, derivatives of 2 and 17 display no affinity for PCP sites and must consequently lack those structural features important for the binding of benzomorphans at PCP sites. Because 3-phenylpiperidines and related sigma-ligands also possess a phenylalkylamine imbedded within their structures, we propose that the 2-phenylaminoethane moiety is a common sigma-pharmacophore for derivatives of 2, the 3-phenylpiperidines, and the sigma-opiates.

Synthesis and structure-activity relationships of N,N'-di-o-tolylguanidine analogues, high-affinity ligands for the haloperidol-sensitive sigma receptor.

With an eye toward the development of novel atypical antipsychotic agents, we have studied the structure-affinity relationships of N,N'-di-o-tolylguanidine (DTG, 3) and its congeners at the haloperidol-sensitive sigma receptor. A number of DTG analogues were synthesized and evaluated in in vitro radioligand displacement experiments with guinea pig brain membrane homogenates, using the highly sigma-specific radioligands [3H]-3 and [3H]-(+)-3-(3-hydroxyphenyl)-N-(1-propyl)piperidine and the phencyclidine (PCP) receptor specific compounds [3H]-N-[1-(2-thienyl)-cyclohexyl]piperidine and [3H]-(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10- imine. The affinity of N,N'-diarylguanidines for the sigma receptor decreases with increasing steric bulk of ortho substituents larger than C2H5. Hydrophobic substituents are generally preferred over similarly positioned hydrophilic ones. Furthermore, electroneutral substituents are preferred over strongly electron donating or withdrawing groups. Significant binding to the sigma receptor is usually retained as long as at least one side of the guanidine bears a preferred group (e.g. 2-CH3C6H5). Replacement of one or both aryl rings with certain saturated carbocycles (e.g. cyclohexyl, norbornyl, or adamantyl) leads to a significant increase in affinity. By combining the best aromatic and best saturated carbocyclic substituents in the same molecule, we arrived at some of the most potent sigma ligands described to date (e.g. N-exo-2-norbornyl-N'-(2-iodophenyl)guanidine, IC50 = 3 nM vs [3H]-3). All of the compounds tested were several orders of magnitude more potent at the sigma receptor than at the PCP receptor, with a few notable exceptions. This series of disubstituted guanidines may be of value in the development of potential antipsychotics and in the further pharmacological and biochemical characterization of the sigma receptor.