Value of CTA/MRA in the setting of intraparenchymal hemorrhage in the emergency department.

PURPOSE: To assess the diagnostic yield of computed tomography angiography (CTA)/magnetic resonance angiography (MRA) brain and neck ordered in the emergency department (ED) for patients who have intraparenchymal hemorrhage (IPH) on their initial noncontrast CT (NCCT) of the head. METHODS: In this retrospective study, we reviewed 156 patients presenting to the ED with nontraumatic IPH, documented on NCCT. We assessed if the subsequent CTA/MRA was positive, and collected data regarding the location of the bleed, patients' age group, and presence/absence of associated SAH/IVH. Two neuroradiologists were asked to predict, based on age and NCCT appearance, whether the CTA/MRA would be positive or negative for demonstrating a vascular etiology of the hemorrhage. RESULTS: The yield of CTA/MRA head for patients above 75 years old was 2% (1/49), as the etiology for IPH in such age group was more commonly related to hypertensive bleed or amyloid angiopathy. The concomitant presence of subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH), particularly in patients younger than 75 years, correlated with a higher likelihood of a positive CTA. Statistically, the neuroradiologists were able to exclude a vascular source of the IPH based on CT appearance, bleed location, and patient's age in over 92% of cases. CONCLUSION: CTA/MRA for IPH has a lower yield in patients at older age and with deep gray matter distribution without SAH. Neuroradiologists were accurate at excluding a vascular source of the IPH in most cases. This study suggests that CTA/MRA can be omitted in certain scenarios, thereby preventing overutilization, and leading to optimal use of health care resources.

Neoplastic Meningitis and Paraneoplastic Syndromes.

Neoplastic meningitis (NM) and paraneoplastic syndromes (PNSs) are a rare group of disorders present in patients with cancer. Clinical diagnosis of these conditions is challenging, and imaging and laboratory analysis play a significant role in diagnosing. Diagnosis of NM largely depends on documenting circulating tumor cells in the cerebrospinal fluid (CSF) and/or leptomeningeal and nodular enhancement on contrast-enhanced MR imaging of the brain or axial spine. PNSs encompass a variety of symptoms or syndromes. Paraneoplastic neuronal disorder diagnosis requires a multidimensional approach, high clinical suspicion, CSF and serum examination, and imaging. Neuroimaging is an integral part in the evaluation.

DNM1 Mutation in a child associated with progressive bilateral mesial temporal sclerosis.

This case represents a novel association of a DNM1 gene mutation with status epilepticus and progressive bilateral mesial temporal sclerosis. This could have future implications for treatment in patients with DNM1 mutation and refractory epilepsy as the mesial temporal sclerosis may become bilateral, making the patient a poor surgical candidate.

Guidelines for radiographic imaging of cranial neuropathies.

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

End-organ radiographic manifestations of cranial neuropathies: A concise review.

BACKGROUND: Cranial neuropathies are a spectrum of disorders associated with dysfunction of one or more of the twelve cranial nerves and the subsequent anatomic structures they innervate. OBJECTIVE: The purpose of this article is to review radiographic imaging findings of end-organ aberrations secondary to cranial neuropathies. METHOD: All articles related to cranial neuropathies were retrieved through the PubMed MEDLINE NCBI database from January 1, 1991 to August 31, 2014. These manuscripts were analyzed for their relation to cranial nerve end-organ disease pathogenesis and radiographic imaging. RESULTS: The present review reveals detectable end-organ changes on CT and/or MRI for the following cranial nerves: olfactory nerve, optic nerve, oculomotor nerve, trochlear nerve, trigeminal nerve, abducens nerve, facial nerve, vestibulocochlear nerve, glossopharyngeal nerve, vagus nerve, accessory nerve, and hypoglossal nerve. CONCLUSION: Radiographic imaging can assist in the detailed evaluation of end-organ involvement, often revealing a corresponding cranial nerve injury with high sensitivity and diagnostic accuracy. A thorough understanding of the distal manifestations of cranial nerve disease can optimize early pathologic detection as well as dictate further clinical management.

Dermal Sinus Tract of Lumbosacral Spine in Children: Patterns on Magnetic Resonance Imaging and Scoring System.

Purpose Dermal sinus tract (DST) is a challenging clinical diagnosis in children. The purpose of our study was to analyze the added value of magnetic resonance imaging (MRI) in the diagnosis of DST involving the lumbosacral spine. We also sought to establish an MRI-based scoring system to simplify the diagnosis of DST. Methods MRI images of 20 patients with clinically suspected DST were retrospectively assessed by two neuroradiologists blinded to the surgical results. The MRI studies were performed from July 2003 to July 2013. Institutional Review Board (IRB) approval was obtained. All MRI studies were assessed with respect to five imaging signs: A) visualization on both sagittal and axial images, B) dural penetration, C) associated tethered cord, D) presence of tumor or inflammation, and E) attachment to conus medullaris. The frequency of each imaging sign in the study population was calculated. For the 20 patients who underwent surgery, sensitivity and specificity of each neuroradiologist's interpretation of the MRI data were calculated using operative findings as the gold standard. Results Twelve of the 20 had confirmed DSTs. The incidences of the five imaging signs were as follows: A) visualization on both sagittal and axial images (12/12, 100%), B) dural penetration (10/12, 83.3%), C) associated tethered cord (7/12, 58.3%), D) presence of tumor or inflammation (4/12, 33.3%), and E) attachment to the conus medullaris (4/12, 33.3%). The best combination of findings predictive of DST was simply the appearance of DST on both axial and sagittal imaging, which resulted in a sensitivity of 100% and a specificity of 75-100%. Conclusion Visualization of DST on both axial and sagittal imaging is the best marker for pathology proven DST. Using a higher threshold score on the five-point scoring system that we proposed did not increase sensitivity or specificity in the diagnosis of DST; however, it may still prove clinically helpful in standardizing reporting leading to a more accurate and detailed assessment.

The effect of aging on the anatomic position of the thyroid gland.

Thyroid disease is common among elderly patients, frequently necessitating thyroid gland examination, imaging, and surgery. However, no prior studies have determined the effect of age on the anatomic position of the thyroid gland in the anterior neck. We hypothesized that the thyroid gland resides at a more caudal position in the neck in elderly patients as compared to younger patients. Head and neck CT scans were collected from 122 atraumatic patients without thyroid disease aged 18-39 years, 40-59 years, 60-79 years, and 80+ years. Measurements of thyroid gland position and other aspects of head and neck anatomy were conducted in the mid-sagittal plane. The distance between the thyroid gland and the sternal notch decreased from 45 ± 10.4 mm in the 18-39 age group to 30.8 ± 9 mm in the 80+ age group (P < 0.001). The position of the gland did not change significantly relative to anatomic landmarks in the head or neck, although the trachea was angled more closely to the horizontal plane in elderly patients (P < 0.001). Cervical spine height was also lower among patients ≥60 years of age compared to those <60 years of age (P < 0.001). Multivariate linear modeling suggested that thyroid gland position was dependent on changes in cervical spine height, hyoid bone to hard palate distance, and tracheal angle (P = 1.7 × 10-11 ; r2 = 0.37). Clinicians should be aware of the more caudad positioning of the gland when planning surgery or screening for thyroid disease in the elderly. Clin. Anat. 30:205-212, 2017. © 2016 Wiley Periodicals, Inc.

Epstein-Barr virus encephalitis presenting as cerebellar hemorrhage.

Epstein-Barr virus (EBV) belongs to the human herpesvirus family and is ubiquitously found in the adult human population. The most common clinical manifestation of EBV is the syndrome of infectious mononucleosis. Central nervous system involvement by EBV is rare, with very few cases of EBV encephalitis reported in the literature. The majority of these cases report cerebral cortical changes on magnetic resonance imaging. We present a rare case of EBV encephalitis in a young patient with meningitis-like symptoms and cerebellar hemorrhage on magnetic resonance imaging.

Imaging of spinal injury in abusive head trauma: a retrospective study.

BACKGROUND: Spinal imaging has been a neglected part of abusive head trauma (AHT) imaging. As most of the radiographs and CT spine are negative in AHT in infants, the cervical spine is assumed to be normal. There is increasing evidence in the role of injury to brainstem and cervical cord in the pathogenesis of AHT. In addition, in courts of law, there is fierce debate about AHT, its mimics and other disparate nontraumatic diagnoses explaining the neuroradiological and skeletal findings. However, this discussion ignores the evidence and significance of spinal injury. We sought to study the cervical spine in an AHT cohort to understand the true prevalence of spinal injuries in AHT and contrast it with cohorts of accidental and nontraumatic groups to give the clinicians a robust diagnostic tool in evaluating AHT. OBJECTIVE: The purpose of this study is to compare the relative incidence of spinal ligamentous and soft-tissue abnormalities on spinal MRI among three groups of children ages <48 months: 1) those with AHT, 2) those with accidental trauma, and 3) those with nontraumatic conditions. MATERIALS AND METHODS: This comparative study included 183 children who underwent spine MRI: 67 with AHT, 46 with accidental trauma and a clinical suspicion of spinal injury, and 70 with nontraumatic conditions. Clinical and radiographic findings were collected in all cases and were analyzed retrospectively to identify MRI evidence of traumatic spinal injuries. The incidence of spinal injuries among the three groups was compared. The incidence of spinal ligamentous injuries was calculated for those with and without radiographic evidence of hypoxic-ischemic encephalopathy. All comparisons were performed using Fisher exact test with P < 0.05 considered statistically significant. RESULTS: Cervical spine ligamentous injuries (predominantly the nuchal, atlanto-occipital and atlanto-axial ligaments) were present in 78% of the AHT group, 46% of the accidental trauma group and 1% of the nontraumatic group; all of these differences were statistically significant. Among the AHT group, ligamentous injuries were statistically correlated with evidence of brain ischemia. CONCLUSION: Injury to the cervical spinal posterior ligamentous complex is common in AHT and even more prevalent than in clinically symptomatic traumatic cases. The high correlation between the radiographic findings of occipitocervical ligamentous injuries and hypoxic-ischemic brain injury is consistent with an interpretation that transient upper occipitocervical spinal cord injury in AHT leads to disordered breathing and results in hypoxic-ischemic encephalopathy. We recommend imaging the entire spine in AHT to properly identify and classify these injuries.

Development and standardization of Morningness-Eveningness Questionnaire (MEQ) in the Indian language Kannada.

INTRODUCTION: A circadian rhythm is any biological process that displays an endogenous, entrainable, oscillation of about 24 hours; the rhythms driven by a circadian clock and sleep have been widely observed in plants, animals, fungi and cyanobacteria. The main aim of the current study was to translate and validate the Morningness-Eveningness Questionnaire (MEQ) to Kannada (MEQ-K). MATERIALS AND METHODS: The English version of MEQ was translated to Kannada using translation-back-translation method. Further it was given to 30 native Kannada speakers for content validation. The final MEQ-Kannada version was then administered on 93 normal native Kannada speakers. Statistical analysis was carried out using SPSS 17.0 software. Statistics such as mean, standard deviation and variance and reliability statistics such as Cronbach's alpha score as well as item-total correlation were obtained. RESULTS: RESULTS showed that, MEQ-K has a Cronbach's alpha score of 0.870 which is considered to be of good reliability. It was also observed that, even after deletion of any one item from the MEQ-K, the Cronbach's alpha score remained the same. CONCLUSION: From the current results it can be stated that, MEQ-K is a reliable tool that can categorize Kannada speaking population into various circadian types.

The effect of circadian rhythm on the perceived tinnitus severity: A preliminary study.

INTRODUCTION: Hearing sound that does not originate in the world outside the body is an experience every human has at one time or another in life. Circadian rhythm is common for all living organisms and nearly all physiological functions, especially sleep-wake cycles, exhibit circadian rhythmicity. A short survey conducted in the study center revealed that majority of the tinnitus subjects reported a difference in tinnitus severity across the day. So the current study focused on finding out the influence of circadian rhythm on tinnitus severity. MATERIALS & METHODS: Study was conducted on 20 tinnitus subjects irrespective of age, gender, hearing status and type of tinnitus. Kannada version of MEQ was given to all the subjects to classify them to various circadian types. A visual analog scale was also given to rate the severity of the tinnitus in the morning and evening. RESULTS: The result of the current study states that, there was a significant difference in the tinnitus severity for moderate morning type individuals in the morning and evening and not for the intermediate group. CONCLUSION: So we can conclude that, circadian rhythm has a strong association with the severity of the tinnitus.

Development and standardization of tinnitus handicap inventory in malayalam.

INTRODUCTION: Tinnitus is defined as the perception of sound mainly due to the activity within the central nervous system without any mechanical, vibratory activity within the cochlea. Administration of tinnitus related questionnaires along with the audiological test battery is recommended in routine clinical practice. Tinnitus Handicap Inventory (THI) is one of the useful and widely recognized tools for quantifying the impact of tinnitus on daily life. India, being a multilingual country with a multicultural background, there is no such inventories available in many of the local Indian languages except in Tamil and Kannada. MATERIALS & METHODS: The English THI was translated to Malayalam by a faculty who is qualified and proficient in Malayalam language. Then the translated THI was given to 40 native Malayalam speakers for content validity. The final THI-M was administered on 50 tinnitus patient. Obtained data was then subjected for statistical analysis using SPSS Statistics 17.0. RESULTS: Reliability statistics revealed an alpha score of 0.855 for the overall inventory. Across the three subscales, i.e. emotional, functional and catastrophic, a global alpha score of 0.766, 0.693 and 0.630, respectively. The alpha score remained the same even after deleting any single item. CONCLUSION: The results of the current study conclude that, THI-M has a good reliability/internal consistency as per the Cronbach's alpha score. THI-M can be considered as a reliable tool that can be used across the State by Hearing Professionals in assessment and management.

Parotid space: anatomic imaging.

The authors present imaging anatomy of the parotid space and discuss non-neoplastic lesions, autoimmune disorders, cysts, neoplastic lesions, epithelial tumors, and nonepithelial lesions. They describe the diseases and their appearance on imaging, describing how the differential diagnoses appear, along with presenting examples of the images, primarily computed tomography and magnetic resonance imaging.

Imaging of stroke: Part 2, Pathophysiology at the molecular and cellular levels and corresponding imaging changes.

OBJECTIVE: Stroke is the third leading cause of death and the leading cause of severe disability. During the "decade of the brain" in the 1990s, the most promising development was the treatment of acute ischemic stroke. It is thought to result from a cascade of events from energy depletion to cell death. In the initial minutes to hour, clinical deficit does not necessarily reflect irreversible damage. The final outcome and residual deficit will be decided by how fast reperfusion is achieved, which in turn depends on how early the diagnosis is made. This article explains the pathophysiology of stroke at the molecular and cellular levels with corresponding changes on various imaging techniques. CONCLUSION: The pathophysiology of stroke has several complex mechanisms. Understanding these mechanisms is essential to derive neuroprotective agents that limit neuronal damage after ischemia. Imaging and clinical strategies aimed at extending the therapeutic window for reperfusion treatment with mechanical and pharmacologic thrombolysis will add value to existing treatment strategies. Acute ischemic stroke is defined as abrupt neurologic dysfunction due to focal brain ischemia resulting in persistent neurologic deficit accompanied by characteristic abnormalities on brain imaging. Knowledge of the pathophysiologic mechanisms of neuronal injury in stroke is essential to target treatment. Neuroprotective and thrombolytic agents have been shown to improve clinical outcome. Physiologic imaging with diffusion-weighted imaging (DWI) and perfusion CT and MRI provide a pathophysiologic substrate of evolving ischemic stroke.

Development and standardization of tinnitus handicap inventory in Kannada.

INTRODUCTION: Tinnitus Handicap Inventory (THI) was developed in English to quantify the handicap caused due to tinnitus. According to a survey conducted by USA, 40 million people are affected by tinnitus. OBJECTIVES: India being a multilingual country needs to develop and standardize THI in Indian languages. The present study concentrates on Developing and Standardizing THI in Kannada. MATERIALS AND METHODS: Questions from English version of THI were translated and modified by two professionals who have a degree of MA Kannada. Translated inventory was given to 50 native Kannada speakers for the familiarity check & the most familiar sentences were included in the study. Tinnitus questionnaire was then administered, followed by the Kannada version of THI on 140 patients and total scores were obtained. RESULTS: Analysis revealed 14% of the patients fall under the category of Slight, 38% under Mild, 26% under Moderate, 16% under Severe and 6% under Catastrophic group. An item total correlation and Cronbach-alpha test was administered to examine the reliability measures and the scores were 0.883 and 0.885 on standardized item. CONCLUSION: Scores of Cronbach-alpha test shows that Kannada version of THI is a standard and reliable tool for measuring the handicap caused by tinnitus and can successfully classify individuals on a severity basis.