Synthetic MRI in children with tuberous sclerosis complex.

OBJECTIVE: The generation of numerous sequences and quantitative data in a short scanning time is the most potential advantage of Synthetic MRI (SyMRI). We aimed to test detection of the tubers and to determine underlying tissue characteristics, and morphometric alterations in the brain of pediatric tuberous sclerosis complex (TSC) patients, using SyMRI. METHODS: Conventional brain MRI (cMRI) and SyMRI were prospectively obtained from 10 TSC patients and 18 healthy control subjects (HCs). Two neuroradiologists independently evaluated tubers on both scans. Additionally, automatically segmented volume calculation and myelin quantification, including the subcortical part of the tubers and normal-appearing brain parenchyma (NABP) of patients, were carried out using SyMRI. RESULTS: The cMRI and SyMRI comparison showed a very good correlation on the detection of the tubers (k = 0.82-0.94). Automatic segmentation of Non-gray matter/white matter/cerebrospinal fluid (Non), %Non/brain parenchymal volume, and %Non/intracranial volume was significantly higher; however, %Myelin/intracranial volume and %Myelin/brain parenchymal volume were significantly lower in the TSC patients (p < 0.05). The proton density values were significantly increased, and myelin fraction volume and myelin-correlated compound values were significantly decreased in the NABP in TSC patients on myelin maps (p < 0.05). The white-matter volume, myelin and white-matter fractional volume, longitudinal relaxation rate, transverse relaxation rate, and myelin-correlated compound values were significantly decreased in the subcortical part of tubers on quantification maps (p < 0.001) in TSC patients. CONCLUSION: SyMRI enables the detection of cortical tubers and is a developing tool in the quantification of morphometric and tissue alterations in pediatric TSC patients with a rational scanning time.

CT dose management for neurologic events in patients with cardiac devices: Radiation exposure variation in patients with cardiac devices.

PURPOSE: To compare the inter-center cranial computed tomography (CT) acquisition rates, CT findings, CT related radiation dose, and variability of CT acquisition parameters for neurologic events among patients with implantable cardioverter-defibrillator (ICD) or left ventricular assist device (LVAD). METHODS: A total of 224 patients [ICD group (n = 155) and LVAD group (n = 69)] who had at least one cranial CT scan were enrolled from three medical centers. The variability and effect of the number, indication, and findings of cranial CT scans as well as CT acquisition parameters including tube potential, tube current, tube rotation time (TI), slice collimation (cSL), and spiral or sequential scanning techniques on CT dose index volume (CTDIvol), total dose length product (DLP) were analyzed. RESULTS: The mean DLP value of Center A and mean CTDIvol values of Center A and C were significantly lower than Center B (p < 0.001). The mean CTDIvol and DLP values in the ICD group were substantially lower than the LVAD group (p<0.001). The most potent parameters causing the changes in CTDIvol and DLP were kV, mAs values, and CT scanning technique as sequential or spiral according to multivariate linear regression analysis. CONCLUSION: Cranial CT acquisition parameters and radiation doses vary significantly between centers, which necessitates optimization of cranial CT protocols to overcome the cumulative radiation dose burden in patients with neurologic events.

Reduced myelin in patients with isolated hippocampal sclerosis as assessed by SyMRI.

PURPOSE: Synthetic MRI (SyMRI) enables to quantify brain tissue and morphometry. We aimed to investigate the WM and myelin alterations in patients with unilateral hippocampal sclerosis (HS) with SyMRI. METHODS: Adult patients with isolated unilateral HS and age-matched control subjects (CSs) were included in this study. The SyMRI sequence QRAPMASTER in the coronal plane perpendicular to the hippocampi was obtained from the whole brain. Automatic segmentation of the whole brain was processed by SyMRI Diagnostic software (Version 11.2). Two neuroradiologists also performed quantitative analyses independently from symmetrical 14 ROIs placed in temporal and extratemporal WM, hippocampi, and amygdalae in both hemispheres. RESULTS: Sixteen patients (F/M = 6/10, mean age = 32.5 ± 11.3 years; right/left HS: 8/8) and 10 CSs (F/M = 5/5, mean age = 30.7 ± 7 years) were included. Left HS patients had significantly lower myelin and WM volumes than CSs (p < .05). Myelin was reduced significantly in the ipsilateral temporal lobe of patients than CSs, greater in left HS (p < .05). Histopathological examination including luxol fast blue stain also revealed myelin pallor in all of 6 patients who were operated. Ipsilateral temporal pole and sub-insular WM had significantly reduced myelin than the corresponding contralateral regions in patients (p < .05). No significant difference was found in WM values. GM values were significantly lower in hippocampi in patients than CSs (p < .05). CONCLUSION: SyMRI revealed myelin reduction in the ipsilateral temporal lobe and sub-insular WM of patients with HS. Whether this finding correlates with electrophysiological features and SyMRI could serve as lateralization of temporal lobe epilepsy need to be investigated.

Detection of occult neoplastic infiltration in the corpus callosum and prediction of overall survival in patients with glioblastoma using diffusion tensor imaging.

OBJECTIVE: Corpus callosum (CC) involvement is a poor prognostic factor in patients with glioblastoma (GBM). The purpose of this study was to determine whether diffusion tensor imaging (DTI) can quantify occult tumor infiltration in the CC and predict the overall survival in GBM patients. METHODS: Forty-eight patients with pathologically proven GBM and 17 normal subjects were included in this retrospective study. Patients were divided into four groups based on CC invasion and overall survival: long survivors without CC invasion; short survivors without CC invasion; long survivors with CC invasion; short survivors with CC invasion. All patients underwent DTI at 3T MRI scanner. Fractional anisotropy (FA) and mean diffusivity (MD) values were measured from genu, mid-body, and splenium of the CC. The mean values of these parameters were compared between different groups and Kaplan Meier curves were used for prediction of overall survival. RESULTS: Patients with short survival and CC invasion had the lowest FA values (0.64 ± 0.05) from the CC compared with other groups (p < 0.05). Receiver operator characteristic curve (ROC) analysis indicated that a FA cutoff value of 0.70 was the best predictor for overall survival with an area under the curve (AUC) of 0.77, sensitivity 1, specificity 0.59. Kaplan-Meier survival curves demonstrated that the mean survival time was significantly longer for patients with high FA (>0.70) compared with those with low FA (<0.70) (p < 0.001). CONCLUSIONS: FA values from the CC can quantify occult tumor infiltration and serve as a sensitive prognostic marker for prediction of overall survival in GBM patients.

Metastatic Embryonal Conjunctival Rhabdomyosarcoma in a 4-Year-Old Boy.

The authors report the case of a 4-year-old boy who presented with unilateral ptosis and a mass lesion of palpebral conjunctiva of the left upper eyelid, that had been present for 2 weeks, and had rapidly enlarged. The lesion was salmon colored and was easily distinguished from the conjunctiva. There was no obvious orbital extension in the MRI studies. Excisional biopsy was performed through a conjunctival approach. The histopathology was consistent with embryonal rhabdomyosarcoma. Thoracoabdominal CT scans revealed nodules in both lungs, indicating stage 4 disease. The patient received chemotheraphy and intensity-modulated radiation therapy. Rhabdomyosarcoma confined to the conjunctiva and distant metastasis without orbital involvement is rare. It should be included in the differential diagnosis of any atypical conjunctival mass lesions in children, and histopathology is necessary to establish proper treatment. As the case indicates, detailed systemic evaluation and careful systemic follow up of these patients are mandatory.

Pseudoduplication of the optic disc in moderate myopia.

We report a case of optic disc pseudoduplication without pathological myopia. A 79-year-old woman presented with gradually decreased vision. Fundus examination showed macular drusen in both eyes and subretinal haemorrhage in the left eye. Both optic discs appeared to be tilted and the left optic disc was seen to be inferiorly duplicated. Pseudodoubling of the optic discs can be caused by optic disc and peripapillary chorioretinal colobomas and pathological myopia. Considering that our patient did not have enough axial length to merit a diagnosis of pathological myopia and no pathological fundus lesions typical of elongated sclera, we suggest that acquired pseudoduplication is not a condition unique to pathological myopia, but can occur in all myopic patients. The clinical materials, including ophthalmological examination, fundus fluorescent angiography and MRI scan of the orbit, were reported, and its pertinent literatures were reviewed.

The diagnostic value of magnetic resonance urography using a balanced turbo field echo sequence.

OBJECTIVES: The aim of the study was to compare the inter-observer variability and the accuracy of magnetic resonance urography (MRU) using a thin sectional balanced-turbo field echo (B-TFE) sequence for detecting ureteral calculi and to determine the effect of additional factors (size, density and location of the calculus) on the sensitivity and specificity of the MRU. MATERIALS & METHODS: MRU and CT images were evaluated independently by two radiologists according to presence, density and localization of calculi. The degrees of inter-rater agreement for categorical items were evaluated by the Kappa coefficient. RESULTS: According to the 1st and 2nd observers, the sensitivity of MRU was 65.9 %, 71.8 % and the specificity of MRU was 95.9 %, 100 %, respectively. Inter-observer agreement was 84.6 % for stone detection. The larger size had a better effect on detectability (p < 0.05). Also, the higher density had a better impact on detectability (p < 0.05). CONCLUSION: Our study has shown that B-TFE MRU was useful to detect ureteral calculi. However, B-TFE MRU has low sensitivity and high specificity in comparison with CT images. MRU is a reasonable alternative imaging technique for follow-up periods of selective groups like patients with large urinary stones, children or pregnant patients when ionizing radiation is undesirable. KEY POINTS: • According to 1st and 2nd observers, sensitivity of MRU was 65.9 %, 71.8 %, respectively. • According to 1st and 2nd observers, MRU specificity was 95.9 %, 100 %, respectively. • Interobserver agreement was found to be over 84 % for stone detection. • B-TFE sequence provides calculus follow-up without radiation. • Larger calculi and more dense calculi individually have the better effect on detectability.

Vascular Leiomyoma Presenting as Anterior Knee Pain (Case Report).

Vascular leiomyomas or angioleiomyomas are rare benign solitary smooth muscle tumors that origin usually in the extremities. Most of these tumors are composed of venous vessels. Here in, we report a rare case of subcutaneous vascular leiomyoma of the right knee of a 38 year old woman who was presented with recurrent anterior right knee pain and soft tissue swelling. Clinical findings, magnetic resonance imaging and histopathologic findings of the tumor is discussed. Leiomyomas are not mostly considered in the differential diagnosis by radiologist due to its rarity. Typical imaging and clinical findings of a tumor is an important clue for an accurate and early diagnosis.

Magnetic resonance tagging for diagnosis of focal hypertrophic cardiomyopathy in a child.

Magnetic resonance imaging has become an important diagnostic tool in the differential diagnosis of lesions for evaluation of cardiovascular disorders. In magnetic resonance tagging (MRt), tissue elements are magnetically labeled so that their positions can be tracked as a function of time. Thus, MRt evaluates heart wall motion both qualitatively and quantitatively. We present herein the case of a 12-year-old boy who had chest pain, dyspnea on effort and murmur. On cardiac computed tomography, there was focal thickening of the left ventricular posterior wall, similar to a mass. MRt indicated active displacement and deformation of the tags at the level of the hypertrophic myocardium during systole, as with normal myocardium. Thus, the tagged images supported the diagnosis of focal hypertrophic cardiomyopathy (HCM). In view of these results, MRt should be considered as a useful technique for differentiating between a mass-like focal lesion such as neoplasm and HCM.

Urethral duplication: a rare cause of recurrent urinary infection.

Urethral duplication is quite a rare congenital anomaly with ill-defined aetiology. Patients often present with penile deformity; recurrent urinary infections, urinary incontinence, serosal discharge from the accessory urethra, and difficulty in urinating. Urethral duplication is most commonly grouped according to the Efmann classification. It has 3 main types as Type I, II, and III. There is no consensus on its therapy. There are non-surgical solutions, including follow-up without therapy, as well as many surgical options, including urethral reconstruction. Anatomical urethra and the external sphincter should absolutely be delineated when a surgery is contemplated. We herein report the case of a two-year-old male patient referred to our clinic with recurrent urinary infection, bilateral hydronephrosis and difficulty in urinating who was diagnosed with urethral duplication. We discuss our findings with review of the relevant literature.

Predisposing factors in posterior circulation infarcts: a vascular morphological assessment.

INTRODUCTION: The aim of the study is to assess the effect of shape, diameter, elongation and deviation criteria of basilar artery (BA), convergence angle and diameter variations of vertebral arteries, and concurrent chronic diseases on posterior circulation infarcts. METHODS: Between January 2010 and May 2013, 186 patients who underwent brain and diffusion magnetic resonance imaging (MRI) with suspected cerebrovascular accident and were diagnosed with posterior circulation infarct and 120 infarct negative control subjects were included in this case-control retrospective study. Vertebral artery (VA) and BA diameter, right (R) and left (L) VA angles at the level of bifurcation, and BA elongation-deviation, and shape of BA were assessed in a total of 306 subjects. Ischemic lesions in the posterior circulation were classified according to their anatomical location and vascular perfusion areas. RESULTS: No significant difference was noted between the control and patient groups with respect to BA diameter (p = 0.676). The most effective risk factors for posterior circulation infarcts were as follows: BA elongation of 2 or 3, BA transverse location of 2 or 3, increase in left VA angle, and history of hypertension, hypercholesterolemia, and diabetes mellitus. CONCLUSION: Our results suggest that prominent elongation and deviation, C and J shape of BA, and increased L VA angle may be the predictors of at-risk patients in posterior circulation infarcts. Reporting marked morphological BA and VA variations detected at routine brain MRI will aid in selection of patients. Timely detection and treatment of at-risk patients may be life-saving.

Amiodarone induced epididymitis: a case report.

INTRODUCTION: Amiodarone is an effective drug for life-threatening arrhythmias like recurrent ventricular fibrillation and atrial fibrillation. Amiodarone creates rarely genitourinary side effects are seen. These are epididymitis, testicular dysfunction and impotance. Amiodarone aggregates and triggers inflammation in the head of the epididym. CASE REPORT: We present the case of a patient who developed epididymitis after 17 months of amiodarone therapy, using a low dose (100 mg per day). Although cessation of medication or dose lowering was not performed, remission of the patient only by analgesics is a distinct case reported in urological literature. CONCLUSIONS: This case stresses the importance of considering an adverse effect of amiodarone treatment as a cause when making a differential diagnosis of epididymitis.

Effect of topical tetracycline on seroma formation in the Lichtenstein technique: a prospective randomized study.

We sought to investigate whether application of topical tetracycline has a limiting effect on seroma formation in patients undergoing hernia repair using a polypropylene mesh. This study was conducted in 96 patients undergoing an elective groin hernia repair. Patients were randomized and divided into 2 groups. After the graft was placed, and before external oblique muscle aponeurosis was closed, 5 mL tetracycline was administered on the graft in the tetracycline group (tetra group, n = 50), and 5 mL isotonic saline was administered in the control group (n = 46) without putting in a drain. Seroma checks via surface ultrasonography were done. Seroma amounts measured on the first day were significantly higher in the tetra group (P = 0.04). There were no significant differences regarding seroma measurements on the seventh day or in the first and second months. Topical tetracycline application has no limiting effect on seroma formation after a groin hernia operation.

Skin-to-stone distance has no impact on outcomes of percutaneous nephrolithotomy.

OBJECTIVE: Skin-to-stone distance (SSD) is a stronger factor than body mass index in predicting the success of shock wave lithotripsy. We aimed to evaluate the impact of SSD on outcomes of percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The medical records of 1,280 patients who had undergone PCNL between April 2007 and February 2012 were evaluated retrospectively. 192 patients who had had preoperative non-contrasted computed tomography and single renal access were included the study. According to this median SSD value, patients were divided into two groups: group 1 (SSD ≤94 mm) (n = 92) and group 2 (SSD >94 mm) (n = 90). The groups were compared according to operative and postoperative parameters. RESULTS: We found no significant differences between the two groups with regard to stone-free rate, operation time, fluoroscopy time, hospitalization time, visual analog score of pain, stone burden, transfusion rates and complication rates. On the other hand, the mean body mass index of group 1 was significantly lower than that of group 2 (p < 0.05). CONCLUSIONS: In this retrospective review of patients undergoing PCNL, we found that SSD has no impact on operative and postoperative outcomes. These results were in accordance with the safety of PCNL in obese patients.

The importance of craniovertebral and cervicomedullary angles in cervicogenic headache.

PURPOSE: Many studies have indicated that cervicogenic headache may originate from the cervical structures innervated by the upper cervical spinal nerves. To date, no study has investigated whether narrowing of the craniovertebral angle (CVA) or cervicomedullary angle (CMA) affects the three upper cervical spinal nerves. The aim of this study was to investigate the effect of CVA and/or CMA narrowing on the occurrence of cervicogenic headache. MATERIALS AND METHODS: Two hundred and five patients diagnosed with cervicogenic headache were included in the study. The pain scores of patients were determined using a visual analog scale. The nonheadache control group consisted of 40 volunteers. CVA and CMA values were measured on sagittal T2-weighted magnetic resonance imaging (MRI), on two occasions by two radiologists. Angle values and categorized pain scores were compared statistically between the groups. RESULTS: Intraobserver and interobserver agreement was over 97% for all measurements. Pain scores increased with decreasing CVA and CMA values. Mean angle values were significantly different among the pain categories (P < 0.001). The pain score was negatively correlated with CMA (Spearman correlation coefficient, rs, -0.676; P < 0.001) and CVA values (rs, -0.725; P < 0.001). CONCLUSION: CVA or CMA narrowing affects the occurrence of cervicogenic headache. There is an inverse relationship between the angle values and pain scores.

MRI findings of lumbosacral metastasis from occult follicular thyroid cancer: report of a case.

A 63-year-old female was admitted to our hospital with bowel and bladder incontinence. Magnetic resonance imaging (MRI) showed a 13 × 12 × 12 cm mass invading the posterior regions of the L4, L5, S1 and S2 vertebrae with broad paravertebral soft tissue invasion. A Tru-cut biopsy of the mass was performed. The histopathological examination revealed metastatic follicular carcinoma of the thyroid. Thyroid functional tests were within the normal limits. Thyroid sonography revealed a heterogeneous, ill-defined, 14 × 9 mm hypoechoic solid nodule in the right lobe of the thyroid gland. On thyroid scintigraphy, an area of focal hyperactivity was detected in the right lobe at the nodule localization. Total thyroidectomy was performed, and the primary tumor pathology was determined to be follicular thyroid cancer. To our knowledge, only a few cases of lumbosacral cord compression as the initial manifestation of follicular thyroid carcinoma have been reported in the literature. We aimed to discuss the MRI findings of tumors in this age group with lumbosacral localization.

Body mass index, cholecystitis, cholelithiasis, pancreatitis and imaging of common bile duct stones.

PURPOSE: Studies to date have not investigated whether body mass index (BMI) affects the sensitivity and specificity of magnetic resonance cholangiopancreatography (MRCP). The purpose of this study was to investigate the effect of BMI and also concomitant pancreatitis, cholecystitis and cholelithiasis on the sensitivity and specificity of MRCP. MATERIALS AND METHODS: Between January 2004 and December 2011, 185 patients were included in the study and divided into 3 groups according to BMI as normal, overweight or obese. Both MRCP and endoscopic retrograde cholangiopancreatography (ERCP) were performed in all patients. ERCP was accepted as the "gold standard." The accuracy, sensitivity and specificity values of the 3 groups were calculated to determine any effects on the results of the MRCP. RESULTS: Before separating into groups according to BMI, the statistical results for MRCP in the detection of stone disease were as follows: specificity 74.3%, sensitivity 81.7% and accuracy 79%. After dividing the patients into 3 groups according to BMI, the specificity of stone detection with MRCP in the normal-weight group was 93.8% but decreased to 65.5% in the overweight group and to 72% in the obese group. The sensitivity of stone detection with MRCP in the normal-weight group was 85.2% but decreased to 75% in the overweight group and increased to 88.9% in the obese group. The accuracy was 88.3% in the normal-weight group but decreased to 71.6% in the overweight group and to 81.9% in the obese group. CONCLUSION: Our study showed that MRCP performance was decreased in the overweight and obese groups.

An unusual case of Candida infection producing a fungus ball in the left atrial cavity.

We report the case of a 75-year-old male patient who was treated in our clinic for septicemia and subacute infective endocarditis caused by toxigenic Candida albicans. Transthoracic echocardiography revealed the presence of a thrombus in the left atrial cavity, and the diagnosis was confirmed by computerized tomography. The patient was operated on urgently. Histological examination of the embolic material removed from the left atrium showed the presence of yeast and hyphal forms of Candida albicans through periodic acid-Shiff stain. The patient was readmitted to the hospital on postoperative day 15, because of reembolism, and died later on. Here we present our approach to the diagnosis and treatment of this rare condition.