Multi-modality imaging evaluation of the dorsal arachnoid web.

PURPOSE: Dorsal arachnoid web (DAW) is a rare intradural abnormality which is associated with progressive myelopathy. Our objective was to review multi-modality imaging techniques demonstrating the scalpel sign appearance in evaluation of DAW. METHODS: We retrospectively reviewed various imaging modalities of patients found to have DAW at our institution during January 2015 to February 2020. Five patients underwent surgical decompression with pathological correlation. The remaining patients were presumptively diagnosed based on the characteristic finding of scalpel sign. Clinical data were evaluated and correlated to imaging findings. All imaging modalities demonstrated the characteristic scalpel sign. RESULTS: Sixteen patients (10 females, and six males) with multi-imaging modalities were evaluated. Their mean age was 52 year (range 23-74 years). Fifteen patients underwent conventional spine MRI. Further high-resolution MR imaging techniques, e.g. 3D T2 myelographic sequence, were utilized with two patients. MRI spine CSF flow study was performed to evaluate the flow dynamic across the arachnoid web in one patient. Eight patients were evaluated with CT myelogram. Syrinx formation was discovered in seven (44%) patients; five (71%) of them underwent surgical resection and decompression. Two patients underwent successful catheter-directed fenestration of the web with clinical improvement. We found a statically significant positive correlation between the degree of cord displacement and compression with syrinx formation (r = 0.55 and 0.65 with p-value of 0.03 and 0.009, respectively). CONCLUSION: DAW has characteristic scalpel sign independent of imaging modality. Multi-modality imaging evaluation of DAW is helpful for evaluation and surgical planning.

Predicting Motor Outcome in Acute Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: Predicting motor outcome following intracerebral hemorrhage is challenging. We tested whether the combination of clinical scores and DTI-based assessment of corticospinal tract damage within the first 12 hours of symptom onset after intracerebral hemorrhage predicts motor outcome at 3 months. MATERIALS AND METHODS: We prospectively studied patients with motor deficits secondary to primary intracerebral hemorrhage within the first 12 hours of symptom onset. Patients underwent multimodal MR imaging including DTI. We assessed intracerebral hemorrhage and perihematomal edema location and volume, and corticospinal tract involvement. The corticospinal tract was considered affected when the tractogram passed through the intracerebral hemorrhage or/and the perihematomal edema. We also calculated affected corticospinal tract-to-unaffected corticospinal tract ratios for fractional anisotropy, mean diffusivity, and axial and radial diffusivities. Motor impairment was graded by the motor subindex scores of the modified NIHSS. Motor outcome at 3 months was classified as good (modified NIHSS 0-3) or poor (modified NIHSS 4-8). RESULTS: Of 62 patients, 43 were included. At admission, the median NIHSS score was 13 (interquartile range = 8-17), and the median modified NIHSS score was 5 (interquartile range = 2-8). At 3 months, 13 (30.23%) had poor motor outcome. Significant independent predictors of motor outcome were NIHSS and modified NIHSS at admission, posterior limb of the internal capsule involvement by intracerebral hemorrhage at admission, intracerebral hemorrhage volume at admission, 72-hour NIHSS, and 72-hour modified NIHSS. The sensitivity, specificity, and positive and negative predictive values for poor motor outcome at 3 months by a combined modified NIHSS of >6 and posterior limb of the internal capsule involvement in the first 12 hours from symptom onset were 84%, 79%, 65%, and 92%, respectively (area under the curve = 0.89; 95% CI, 0.78-1). CONCLUSIONS: Combined assessment of motor function and posterior limb of the internal capsule damage during acute intracerebral hemorrhage accurately predicts motor outcome.

Malformaciones vasculares y tumores de partes blandas. Parte 2: lesiones de bajo flujo / Soft-tissue vascular malformations and tumors. Part 2: low-flow lesions

Las malformaciones vasculares y los tumores, también conocidos como "anomalías vasculares", comprenden una extensa variedad de lesiones en diferentes partes del cuerpo. El origen y la histopatología de estas lesiones no es del todo conocido, por ello este campo se ha visto ensombrecido por el uso de una nomenclatura poco clara. Conocer su clasificación, así como las características clínicas y de imagen es de vital importancia para el manejo de estos pacientes. El objetivo de esta serie de dos artículos es revisar la clasificación actual de las anomalías vasculares, describir el papel que desempeñan las pruebas de imagen en su diagnóstico, resumir sus características histopatológicas, clínicas y de imagen y debatir las posibles opciones terapéuticas. El primer artículo de esta serie versó sobre las lesiones de alto flujo. En este segundo artículo nos centraremos en las de bajo flujo, incluidos los síndromes complejos que asocian malformaciones de bajo flujo

Vascular malformations and tumors, also known as "vascular anomalies", comprise an extensive variety of lesions involving all parts of the body. Due to a lack of a complete understanding of the origin and histopathology of such lesions, this field has been traditionally obscured by the use of an unclear nomenclature. Knowledge of the classification and clinical and imaging characteristics of this group of lesions is paramount when managing these patients. The objective of this series of two articles is to review the current classification of vascular anomalies, to describe the role of imaging in their diagnosis, to summarize their distinctive histopathologic, clinical and imaging features, and to discuss the treatment options. High-flow lesions were discussed in the first article of this series. In this second article, we will focus on low-flow lesions, including complex syndromes with associated low-flow malformations

Malformaciones vasculares y tumores de partes blandas. Parte 1: clasificación, papel de las pruebas imagen y lesiones de alto flujo / Soft-tissue vascular malformations and tumors. Part 1: classification, role of imaging and high-flow lesions

Las malformaciones vasculares y los tumores, también conocidos como «anomalías vasculares», comprenden una extensa variedad de lesiones en diferentes partes del cuerpo. Conocer su clasificación y características en las imágenes es de vital importancia. Si bien los hemangiomas son tumores vasculares benignos caracterizados por proliferación celular e hiperplasia, las malformaciones vasculares no son verdaderos tumores y muestran, típicamente, una renovación endotelial normal. Las malformaciones vasculares se clasifican, según el vaso predominante, en arteriales, capilares, venosas, linfáticas o mixtas. La ecografía y la resonancia magnética son las técnicas de imagen que se usan en el diagnóstico y la clasificación de las anomalías vasculares. En esta serie de dos artículos revisaremos la clasificación de las anomalías vasculares, describiremos el papel que desempeñan las pruebas de imagen, resumiremos sus características histopatogénicas, clínicas y de imagen, y comentaremos las posibles opciones terapéuticas. En este primer artículo hablamos de las lesiones de alto flujo, y en el segundo lo haremos de las de bajo flujo. También trataremos los síndromes complejos asociados tanto a los tumores vasculares como a las malformaciones

Vascular malformations and tumors, also known as "vascular anomalies", comprise an extensive variety of lesions involving all parts of the body. Knowledge of their classification and imaging characteristics is paramount. Whereas hemangiomas are benign vascular tumors, characterized by cellular proliferation and hyperplasia; vascular malformations are not real tumors and characteristically exhibit normal endothelial turnover. Vascular malformations are classified according to the predominant vascular channel as arterial, capillary, venous, lymphatic, or mixed. Ultrasound and MRI are the main imaging modalities used in the diagnosis and classification of the vascular anomalies. In this series of two articles we review the classification of vascular anomalies, describe the role of imaging, summarize their distinctive histopathogenic, clinical and imaging features, and discuss the treatment options. On the first article we discuss the high-flow lesions, whereas the slow-flow lesions will be reviewed on the second. Complex syndromes with associated vascular tumors and malformations will be also presented

Soft-tissue vascular malformations and tumors. Part 1: classification, role of imaging and high-flow lesions. / Malformaciones vasculares y tumores de partes blandas. Parte 1: clasificación, papel de las pruebas imagen y lesiones de alto flujo.

Vascular malformations and tumors, also known as "vascular anomalies", comprise an extensive variety of lesions involving all parts of the body. Knowledge of their classification and imaging characteristics is paramount. Whereas hemangiomas are benign vascular tumors, characterized by cellular proliferation and hyperplasia; vascular malformations are not real tumors and characteristically exhibit normal endothelial turnover. Vascular malformations are classified according to the predominant vascular channel as arterial, capillary, venous, lymphatic, or mixed. Ultrasound and MRI are the main imaging modalities used in the diagnosis and classification of the vascular anomalies. In this series of two articles we review the classification of vascular anomalies, describe the role of imaging, summarize their distinctive histopathogenic, clinical and imaging features, and discuss the treatment options. On the first article we discuss the high-flow lesions, whereas the slow-flow lesions will be reviewed on the second. Complex syndromes with associated vascular tumors and malformations will be also presented.

Soft-tissue vascular malformations and tumors. Part 2: low-flow lesions. / Malformaciones vasculares y tumores de partes blandas. Parte 2: lesiones de bajo flujo.

Vascular malformations and tumors, also known as "vascular anomalies", comprise an extensive variety of lesions involving all parts of the body. Due to a lack of a complete understanding of the origin and histopathology of such lesions, this field has been traditionally obscured by the use of an unclear nomenclature. Knowledge of the classification and clinical and imaging characteristics of this group of lesions is paramount when managing these patients. The objective of this series of two articles is to review the current classification of vascular anomalies, to describe the role of imaging in their diagnosis, to summarize their distinctive histopathologic, clinical and imaging features, and to discuss the treatment options. High-flow lesions were discussed in the first article of this series. In this second article, we will focus on low-flow lesions, including complex syndromes with associated low-flow malformations.

Vitamin B12 deficiency and clinical laboratory: Lessons revisited and clarified in seven questions.

The objective of this review article is to address the most frequently asked questions that pathologists and primary care physicians might face when dealing with a patient with suspicion of vitamin B12 deficiency. More specifically, the article mainly discusses the importance and prevalence of the deficit, how to recognize it, and the important role of a prompt diagnosis confirmation based on laboratory biomarkers for efficient replacement therapy.

Clinical and Imaging Characteristics of Arteriopathy Subtypes in Children with Arterial Ischemic Stroke: Results of the VIPS Study.

BACKGROUND AND PURPOSE: Childhood arteriopathies are rare but heterogenous, and difficult to diagnose and classify, especially by nonexperts. We quantified clinical and imaging characteristics associated with childhood arteriopathy subtypes to facilitate their diagnosis and classification in research and clinical settings. MATERIALS AND METHODS: The Vascular Effects of Infection in Pediatric Stroke (VIPS) study prospectively enrolled 355 children with arterial ischemic stroke (2010-2014). A central team of experts reviewed all data to diagnose childhood arteriopathy and classify subtypes, including arterial dissection and focal cerebral arteriopathy-inflammatory type, which includes transient cerebral arteriopathy, Moyamoya disease, and diffuse/multifocal vasculitis. Only children whose stroke etiology could be conclusively diagnosed were included in these analyses. We constructed logistic regression models to identify characteristics associated with each arteriopathy subtype. RESULTS: Among 127 children with definite arteriopathy, the arteriopathy subtype could not be classified in 18 (14%). Moyamoya disease (n = 34) occurred mostly in children younger than 8 years of age; focal cerebral arteriopathy-inflammatory type (n = 25), in children 8-15 years of age; and dissection (n = 26), at all ages. Vertigo at stroke presentation was common in dissection. Dissection affected the cervical arteries, while Moyamoya disease involved the supraclinoid internal carotid arteries. A banded appearance of the M1 segment of the middle cerebral artery was pathognomonic of focal cerebral arteriopathy-inflammatory type but was present in <25% of patients with focal cerebral arteriopathy-inflammatory type; a small lenticulostriate distribution infarct was a more common predictor of focal cerebral arteriopathy-inflammatory type, present in 76%. It remained difficult to distinguish focal cerebral arteriopathy-inflammatory type from intracranial dissection of the anterior circulation. We observed only secondary forms of diffuse/multifocal vasculitis, mostly due to meningitis. CONCLUSIONS: Childhood arteriopathy subtypes have some typical features that aid diagnosis. Better imaging methods, including vessel wall imaging, are needed for improved classification of focal cerebral arteriopathy of childhood.

Utilizing dual energy CT to improve CT diagnosis of posterior fossa ischemia.

BACKGROUND AND PURPOSE: Evaluation of posterior fossa ischemia on conventional CT is limited. The goal of our study was to determine if virtual monochromatic CT increases the diagnostic accuracy for the detection of posterior infarcts relative to standard CT while using diffusion-weighted MRI as a reference standard. METHODS: Thirty consecutive subjects who meet the following inclusion criteria were retrospectively enrolled: (1) symptoms of posterior fossa stroke (e.g. vertigo, fainting, and dizziness), (2) unenhanced dual-energy CT of the head performed upon admission to the emergency department, and (3) MRI of the brain within 7 days following the CT. Eight of the 30 subjects were determined to have MRI diffusion-weighted imaging findings consistent with acute posterior fossa ischemia. Monochromatic energy reconstructions at 60, 80, 100, 120keV and the clinical CT were interpreted independently by two fellowship-trained neuroradiologists, who assessed the images for posterior fossa infarcts and for imaging quality. RESULTS: Reconstructions obtained at 80keV provided the best artifact reduction and overall maximization of image quality and were statistically significantly better than standard head CT (P<0.001). Sensitivity, specificity, positive predictive value, and negative predictive value were at least not less than standard CT, and there was a trend toward better values at 100keV (P=0.096). CONCLUSION: Monoenergetic 80 or 100keV reconstructions may improve the detection of posterior fossa ischemia compared to conventional CT. However, if clinical suspicion for posterior fossa ischemia warrants, a brain MRI with diffusion-weighted imaging should still be obtained, even in the presence of a negative dual energy CT of the brain.

Fontan procedure: imaging of normal post-surgical anatomy and the spectrum of cardiac and extracardiac complications.

Univentricular congenital heart diseases include a range of entities that result in a functionally single ventricular chamber. Although the only curative therapy is cardiac transplantation, there are several palliative surgical techniques that prevent ventricular volume overload, diverting part or all the systemic venous circulation into the pulmonary arteries. The modern Fontan procedure, which consists of anastomosing both the superior (SVC) and inferior vena cava (IVC) to the right pulmonary artery (RPA), is nowadays the last step before transplantation. The importance of imaging in these entities lies not only in the understanding of the new circuit established after surgical correction, but also in the early detection of the wide spectrum of cardiac and extracardiac complications that can occur due to the new physiological condition. Due to the increased survival of these patients, long-term complications are becoming more common. The main cardiac complications are atrial enlargement, ventricular dysfunction, and stenosis or thrombosis of the conduit. Pulmonary artery stenosis, pulmonary arteriovenous fistulae (PAVF), systemic-pulmonary veno venous shunts (VVS), hepatic congestion, cardiac cirrhosis, and protein-losing enteropathy are potential extracardiac complications.

Comparación de la capacidad diagnóstica precoz de los biomarcadores de la enfermedad de Alzheimer en resonancia magnética cerebral y líquido cefalorraquídeo / A comparison of early diagnostic utility of Alzheimer disease biomarkers in brain magnetic resonance and cerebrospinal fluid

Introducción: Nuestros objetivos fueron comparar la capacidad de diagnóstico precoz de los biomarcadores (BMC) de enfermedad de Alzheimer (EA) en LCR y RM cerebral, en condiciones posibles de nuestra práctica clínica y, además, conocer la precisión diagnóstica de la combinación de ambas técnicas. Métodos: Entre 2008 y 2009, estudiamos a 30 pacientes con deterioro cognitivo leve (DCL) mediante RM cerebral de 1,5 teslas y análisis de BMC de EA en el LCR. Las RM fueron valoradas por 2 neurorradiólogos, atendiendo a la escala visual de Korf (2004). Los BMC de EA en LCR se analizaron mediante reactivos INNOTEST para proteínas A 1-42, total-tau y fosfo-tau. Se evaluó la evolución clínica (según criterios NINCDS-ADRDA) a los 2 a˜nos tras la inclusión. Resultados: Entre los 30 pacientes iniciales, 15 evolucionaron a EA (criterios NINCDS-ADRDA) a los 2 a˜nos de la inclusión. La capacidad predictiva de los BMC en LCR (RR 2,7; IC del 95%, 1,1-6,7; p < 0,01) es superior a los de RM (RR 1,5; IC del 95%, 0,7-3,4; p < 0,2), y la combinación de ambas técnicas alcanza una sensibilidad y valor predictivo negativo del 100%. La normalidad de ambas pruebas complementarias descartó al 100% el desarrollo de EA, en los 2 a˜nos siguientes a la realización de las mismas. Conclusiones: Siguiendo nuestra metodología, la precisión diagnóstica de los BMC en LCR es superior a los de la RM para el diagnóstico precoz de EA. La combinación de ambas técnicasconsigue una precisión diagnóstica muy alta, tanto para diagnosticar como para excluir precozmente EA, en pacientes con DCL

Introduction: The goals of this study were to compare the early diagnostic utility of Alzheimer disease biomarkers in the CSF with those in brain MRI in conditions found in our clinical practice, and to ascertain the diagnostic accuracy of both techniques used together. Methods: Between 2008 and 2009, we included 30 patients with mild cognitive impairment (MCI) who were examined using 1.5 Tesla brain MRI and AD biomarker analysis in CSF. MRI studies were evaluated by 2 radiologists according to the Korf s visual scale. CSF biomarkers were analysed using INNOTEST reagents for A 1-42, total-tau and phospho-tau181p. We evaluated clinical changes 2 years after inclusion. Results: By 2 years after inclusion, 15 of the original 30 patients (50%) had developed AD (NINCDS-ADRA criteria). The predictive utility of AD biomarkers in CSF (RR 2.7; 95% CI, 1.1-6.7; P < .01) was greater than that of MRI (RR 1.5; 95% CI 95%, 0.7-3.4; P < .2); using both techniques together yielded a sensitivity and a negative predictive value of 100%. Normal results on both complementary tests ruled out progression to AD (100%) within 2 years of inclusion. Conclusions: Our results show that the diagnostic accuracy of biomarkers in CSF is higher than that of biomarkers in MRI. Combined use of both techniques is highly accurate for either early diagnosis or exclusion of AD in patients with MCI

Dental flat panel conebeam CT in the evaluation of patients with inflammatory sinonasal disease: Diagnostic efficacy and radiation dose savings.

BACKGROUND AND PURPOSE: CT is the imaging modality of choice to study the paranasal sinuses; unfortunately, it involves significant radiation dose. Our aim was to assess the diagnostic validity, image quality, and radiation-dose savings of dental conebeam CT in the evaluation of patients with suspected inflammatory disorders of the paranasal sinuses. MATERIAL AND METHODS: We prospectively studied 40 patients with suspected inflammatory disorders of the sinuses with dental conebeam CT and standard CT. Two radiologists analyzed the images independently, blinded to clinical information. The image quality of both techniques and the diagnostic validity of dental conebeam CT compared with the reference standard CT were assessed by using 3 different scoring systems. Image noise, signal-to-noise ratio, and contrast-to-noise ratio were calculated for both techniques. The absorbed radiation dose to the lenses and thyroid and parotid glands was measured by using a phantom and dosimeter chips. The effective radiation dose for CT was calculated. RESULTS: All dental conebeam CT scans were judged of diagnostic quality. Compared with CT, the conebeam CT image noise was 37.3% higher (P < .001) and the SNR of the bone was 75% lower (P < .001). The effective dose of our conebeam CT protocol was 23 µSv. Compared with CT, the absorbed radiation dose to the lenses and parotid and thyroid glands with conebeam CT was 4%, 7.8%, and 7.3% of the dose delivered to the same organs by conventional CT (P < .001). CONCLUSIONS: Dental conebeam CT is a valid imaging procedure for the evaluation of patients with inflammatory sinonasal disorders.

A comparison of early diagnostic utility of Alzheimer disease biomarkers in brain magnetic resonance and cerebrospinal fluid.

INTRODUCTION: The goals of this study were to compare the early diagnostic utility of Alzheimer disease biomarkers in the CSF with those in brain MRI in conditions found in our clinical practice, and to ascertain the diagnostic accuracy of both techniques used together. METHODS: Between 2008 and 2009, we included 30 patients with mild cognitive impairment (MCI) who were examined using 1.5 Tesla brain MRI and AD biomarker analysis in CSF. MRI studies were evaluated by 2 radiologists according to the Korf́s visual scale. CSF biomarkers were analysed using INNOTEST reagents for Aß1-42, total-tau and phospho-tau181p. We evaluated clinical changes 2 years after inclusion. RESULTS: By 2 years after inclusion, 15 of the original 30 patients (50%) had developed AD (NINCDS-ADRA criteria). The predictive utility of AD biomarkers in CSF (RR 2.7; 95% CI, 1.1-6.7; P<.01) was greater than that of MRI (RR 1.5; 95% CI 95%, 0.7-3.4; P<.2); using both techniques together yielded a sensitivity and a negative predictive value of 100%. Normal results on both complementary tests ruled out progression to AD (100%) within 2 years of inclusion. CONCLUSIONS: Our results show that the diagnostic accuracy of biomarkers in CSF is higher than that of biomarkers in MRI. Combined use of both techniques is highly accurate for either early diagnosis or exclusion of AD in patients with MCI.

El Laboratorio Clínico en Atención Sanitaria, ¿proceso clave o de apoyo? / The clinical laboratory in the health care system: a key or a support process?

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Tissue at risk in acute stroke patients treated beyond 8 h after symptom onset.

INTRODUCTION: The decision on thrombolytics administration is usually based on a generalized, rigid time-based rule rather than an individualized evaluation of the "tissue at risk of infarction" which is the target of the recanalization therapies. The goals of our article are to assess whether there is tissue at risk of infarction in a group of acute stroke patients treated beyond 8 h after symptom onset and to investigate the baseline imaging and clinical features that predict the fate of this tissue at risk. METHODS: We retrospectively reviewed a series of patients with acute ischemic stroke treated with endovascular recanalization therapies beyond 8 h after symptom onset. The tissue at risk was calculated as the difference between the infarct volumes on baseline and follow-up imaging (infarct growth). We analyzed the epidemiological distribution of infarct growth, and we performed a multivariate regression analysis to identify the baseline variables that predict infarct growth. RESULTS: Our study group included 75 patients (65 ± 13.8 years, baseline National Institutes of Health Stroke Scale 14 ± 4.9, time to treatment 15.2 ± 8.7 h). The mean infarct growth was 78.6 ± 95.0 cc (p < 0.001), and, overall, the infarct growth was greater when the baseline volume of infarct tissue was small (p < 0.001) and in the case of a unsuccessful arterial recanalization (p = 0.001). CONCLUSIONS: There is potentially salvageable ischemic tissue at risk in acute stroke patients treated beyond 8 h after symptom onset.

Nocardiosis in solid-organ transplant recipients: spectrum of imaging findings.

Nocardiosis is an infrequent but severe infection that primarily affects the lung and thence is able to produce disseminated disease. Prompt diagnosis of pulmonary and disseminated nocardiosis is of utmost importance in solid-organ transplant recipients to reduce mortality. Knowledge of the different radiological manifestations in the appropriate clinical setting is key to successful management of these patients. The aim of this review is to describe the radiological features of nocardiosis in immunosuppressed patients, particularly in solid-organ transplant recipients.