Low-count whole-body PET/MRI restoration: an evaluation of dose reduction spectrum and five state-of-the-art artificial intelligence models.

PURPOSE: To provide a holistic and complete comparison of the five most advanced AI models in the augmentation of low-dose 18F-FDG PET data over the entire dose reduction spectrum. METHODS: In this multicenter study, five AI models were investigated for restoring low-count whole-body PET/MRI, covering convolutional benchmarks - U-Net, enhanced deep super-resolution network (EDSR), generative adversarial network (GAN) - and the most cutting-edge image reconstruction transformer models in computer vision to date - Swin transformer image restoration network (SwinIR) and EDSR-ViT (vision transformer). The models were evaluated against six groups of count levels representing the simulated 75%, 50%, 25%, 12.5%, 6.25%, and 1% (extremely ultra-low-count) of the clinical standard 3 MBq/kg 18F-FDG dose. The comparisons were performed upon two independent cohorts - (1) a primary cohort from Stanford University and (2) a cross-continental external validation cohort from Tübingen University - in order to ensure the findings are generalizable. A total of 476 original count and simulated low-count whole-body PET/MRI scans were incorporated into this analysis. RESULTS: For low-count PET restoration on the primary cohort, the mean structural similarity index (SSIM) scores for dose 6.25% were 0.898 (95% CI, 0.887-0.910) for EDSR, 0.893 (0.881-0.905) for EDSR-ViT, 0.873 (0.859-0.887) for GAN, 0.885 (0.873-0.898) for U-Net, and 0.910 (0.900-0.920) for SwinIR. In continuation, SwinIR and U-Net's performances were also discreetly evaluated at each simulated radiotracer dose levels. Using the primary Stanford cohort, the mean diagnostic image quality (DIQ; 5-point Likert scale) scores of SwinIR restoration were 5 (SD, 0) for dose 75%, 4.50 (0.535) for dose 50%, 3.75 (0.463) for dose 25%, 3.25 (0.463) for dose 12.5%, 4 (0.926) for dose 6.25%, and 2.5 (0.534) for dose 1%. CONCLUSION: Compared to low-count PET images, with near-to or nondiagnostic images at higher dose reduction levels (up to 6.25%), both SwinIR and U-Net significantly improve the diagnostic quality of PET images. A radiotracer dose reduction to 1% of the current clinical standard radiotracer dose is out of scope for current AI techniques.

Comparison of whole-body DW-MRI with 2-[18F]FDG PET for staging and treatment monitoring of children with Langerhans cell histiocytosis.

PURPOSE: To assess and compare the diagnostic accuracy of whole-body (WB) DW-MRI with 2-[18F]FDG PET for staging and treatment monitoring of children with Langerhans cell histiocytosis (LCH). METHODS: Twenty-three children with LCH underwent 2-[18F]FDG PET and WB DW-MRI at baseline. Two nuclear medicine physicians and two radiologists independently assessed presence/absence of tumors in 8 anatomical areas. Sixteen children also performed 2-[18F]FDG PET and WB DW-MRI at follow-up. One radiologist and one nuclear medicine physician revised follow-up scans and collected changes in tumor apparent diffusion (ADC) and standardized uptake values (SUV) before and after therapy in all detectable lesions. 2-[18F]FDG PET results were considered the standard of reference for tumor detection and evaluation of treatment response according to Lugano criteria. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of WB DW-MRI at baseline were calculated, and the 95% confidence intervals were estimated by using the Clopper-Pearson (exact) method; changes in tumor SUVs and ADC were compared using a Mann-Whitney U test. Agreement between reviewers was assessed with a Cohen's weighted kappa coefficient. Analyses were conducted using SAS software version 9.4. RESULTS: Agreement between reviewers was perfect (kappa coefficient = 1) for all analyzed regions but spine and neck (kappa coefficient = 0.89 and 0.83, respectively) for 2-[18F]FDG PET images, and abdomen and pelvis (kappa coefficient = 0.65 and 0.88, respectively) for WB DW-MRI. Sensitivity and specificity were 95.5% and 100% for WB DW-MRI compared to 2-[18F]FDG PET. Pre to post-treatment changes in SUVratio and ADCmean were inversely correlated for all lesions (r: -0.27, p = 0·06) and significantly different between responders and non-responders to chemotherapy (p = 0.0006 and p = 0·003 for SUVratio and ADCmean, respectively). CONCLUSION: Our study showed that WB DW-MRI has similar accuracy to 2-[18F]FDG PET for staging and treatment monitoring of LCH in children. While 2-[18F]FDG PET remains an approved radiological examination for assessing metabolically active disease, WB DW-MRI could be considered as an alternative approach without radiation exposure. The combination of both modalities might have advantages over either approach alone.

Association between Extracranial Carotid Artery Plaque and Cognitive Dysfunction: A Systematic Review and Meta-Analysis.

BACKGROUND: Extracranial carotid atherosclerosis has been variably associated with dementia. Prior studies have focused on the association of carotid intima media thickness or carotid stenosis; however, there is evidence that carotid plaque may contribute to dementia, perhaps via microembolic phenomena. OBJECTIVES: We sought to evaluate the role of carotid plaque in contributing to cognitive impairment by performing a systematic review and meta-analysis to summarize the association between extracranial carotid plaque and cognitive dysfunction and dementia. METHODS: We performed a comprehensive literature search evaluating the association of extracranial carotid plaque with cognition. We included studies measuring carotid plaque on ultrasound, computed tomography, or MR and also evaluated cognition through neuropsychological testing. Meta-analyses with assessment of study heterogeneity and publication bias were performed. Results were presented in a forest plot and summarized using a random-effects model. RESULTS: After screening 1,674 studies, we included 40 for systematic review and 16 and 7 studies for two meta-analyses with a total of 19,029 and 27,325 patients, respectively. We found a positive relationship between the presence of extracranial carotid plaque and cognitive dysfunction with a pooled random-effects odds ratio (OR) of 1.83 (95% CI, 1.50, 2.24) and a pooled random-effects hazard ratio (HR) of 1.47 (95% CI, 1.15, 1.89), respectively. A sensitivity analysis of only longitudinal studies found a persistent positive association. Measures of heterogeneity showed moderate heterogeneity in each meta-analysis, respectively (I-squared statistic = 57% and 70%). CONCLUSION: The presence of extracranial carotid plaque is significantly associated with cognitive dysfunction and dementia in both cross-sectional and longitudinal analyses. After further confirmation, our results support carotid plaque being a potentially modifiable risk factor in the development of dementia.

Idiopathic intracranial hypertension imaging approaches and the implications in patient management.

Idiopathic intracranial hypertension (IIH) represents a clinical disease entity without a clear etiology, that if left untreated, can result in severe outcomes, including permanent vision loss. For this reason, early diagnosis and treatment is necessary. Historically, the role of cross-sectional imaging has been to rule out secondary or emergent causes of increased intracranial pressure, including tumor, infection, hydrocephalus, or venous thrombosis. MRI and MRV, however, can serve as valuable imaging tools to not only rule out causes for secondary intracranial hypertension but can also detect indirect signs of IIH resultant from increased intracranial pressure, and demonstrate potentially treatable sinus venous stenosis. Digital subtraction venographic imaging also plays a central role in both diagnosis and treatment, providing enhanced anatomic delineation and temporal flow evaluation, quantitative assessment of the pressure gradient across a venous stenosis, treatment guidance, and immediate opportunity for endovascular therapy. In this review, we discuss the multiple modalities for imaging IIH, their limitations, and their contributions to the management of IIH.

Clinical applications of diffusion-weighted sequence in brain imaging: beyond stroke.

Diffusion-weighted imaging (DWI) is a well-established MRI sequence for diagnosing early stroke and provides therapeutic implications. However, DWI yields pertinent information in various other brain pathologies and helps establish a specific diagnosis and management of other central nervous system disorders. Some of these conditions can present with acute changes in neurological status and mimic stroke. This review will focus briefly on diffusion imaging techniques, followed by a more comprehensive description of the utility of DWI in common neurological entities beyond stroke.

Asymptomatic Carotid Disease and Cognitive Impairment: What Is the Evidence?

The development of cognitive dysfunction and dementia is a complex, multifactorial process. One of the contributors to various types of cognitive dysfunction is carotid atherosclerosis which can frequently be seen in asymptomatic individuals. There are a number of different manifestations of asymptomatic carotid atherosclerosis including arterial stiffness, carotid intima-media thickening, flow-limiting stenosis, and complex, atherosclerotic plaque. Each of these forms of atherosclerosis may contribute to cerebral parenchymal damage, contributing to cognitive dysfunction. In this review article, we will discuss each of these forms of carotid atherosclerosis, present the potential mechanistic underpinnings behind an association, and then review the scientific evidence supporting potential associations to cognitive dysfunction and dementia.

Accuracy of Machine Learning Models to Predict Mortality in COVID-19 Infection Using the Clinical and Laboratory Data at the Time of Admission.

Aim This study aimed to develop a predictive model to predict patients' mortality with coronavirus disease 2019 (COVID-19) from the basic medical data on the first day of admission. Methods The medical data including the demographic, clinical, and laboratory features on the first day of admission of clinically diagnosed COVID-19 patients were documented. The outcome of patients was also recorded as discharge or death. Feature selection models were then implemented and different machine learning models were developed on top of the selected features to predict discharge or death. The trained models were then tested on the test dataset. Results A total of 520 patients were included in the training dataset. The feature selection demonstrated 22 features as the most powerful predictive features. Among different machine learning models, the naive Bayes demonstrated the best performance with an area under the curve of 0.85. The ensemble model of the naive Bayes and neural network combination had slightly better performance with an area under the curve of 0.86. The models had relatively the same performance on the test dataset. Conclusion Developing a predictive machine learning model based on the basic medical features on the first day of admission in COVID-19 infection is feasible with acceptable performance.

Assessment of Recurrent Stroke Risk in Patients With a Carotid Web.

Importance: A carotid web (CW) is a shelf-like lesion along the posterior wall of the internal carotid artery bulb and an underrecognized cause of young stroke. Several studies suggest that patients with symptomatic CW have a high risk of recurrent stroke, but high-quality data are lacking. Objective: To assess the 2-year risk of recurrent stroke in patients with a symptomatic CW. Design, Setting, and Participants: A comparative cohort study used data from the MR CLEAN trial (from 2010-2014) and MR CLEAN Registry (from 2014-2017). Data were analyzed in September 2020. The MR CLEAN trial and MR CLEAN Registry were nationwide prospective multicenter studies on endovascular treatment (EVT) of large vessel occlusion (LVO) stroke in the Netherlands. Baseline data were from 3439 consecutive adult patients with anterior circulation LVO stroke and available computed tomography (CT)-angiography of the carotid bulb. Two neuroradiologists reevaluated CT-angiography images for presence or absence of CW and identified 30 patients with CW ipsilateral to the index stroke. For these 30 eligible CW participants, detailed follow-up data regarding stroke recurrence within 2 years were acquired. These 30 patients with CW ipsilateral to the index stroke were compared with 168 patients without CW who participated in the MR CLEAN extended follow-up trial and who were randomized to the EVT arm. Main Outcomes and Measures: The primary outcome was recurrent stroke occurring within 2 years after the index stroke. Cox proportional hazards regression models were used to compare recurrent stroke rates within 2 years for patients with and without CW, adjusted for age and sex. The research question was formulated prior to data collection. Results: Of 3439 patients with baseline CT-angiography assessed, the median age was 72 years (interquartile range, 61-80 years) and 1813 (53%) were men. Patients with CW were younger (median age, 57 [interquartile range, 46-66] years vs 66 [interquartile range, 56-77] years; P = .02 and more often women (22 of 30 [73%] vs 67 of 168 [40%]; P = .001) than patients without CW. Twenty-eight of 30 patients (93%) received medical management after the index stroke (23 with antiplatelet therapy and 5 with anticoagulant therapy). During 2 years of follow-up, 5 of 30 patients (17%) with CW had a recurrent stroke compared with 5 of 168 patients (3%) without CW (adjusted hazard ratio, 4.9; 95% CI, 1.4-18.1). Conclusions and Relevance: In this study, 1 of 6 patients with a symptomatic CW had a recurrent stroke within 2 years, suggesting that medical management alone may not provide sufficient protection for patients with CW.

Current Status and Quality of Machine Learning-Based Radiomics Studies for Glioma Grading: A Systematic Review.

INTRODUCTION: Radiomics now has significant momentum in the era of precision medicine. Glioma is one of the pathologies that has been extensively evaluated by radiomics. However, this technique has not been incorporated into clinical practice. In this systematic review, we selected and reviewed the published studies about glioma grading by radiomics to evaluate this technique's feasibility and its challenges. MATERIAL AND METHODS: Using seven different search strings, we considered all published English manuscripts from 2015 to September 2020 in PubMed, Embase, and Scopus databases. After implementing the exclusion and inclusion criteria, the final papers were selected for the methodological quality assessment based on our in-house Modified Radiomics Standard Scoring (RQS) containing 43 items (minimum score of 0, maximum score of 44). Finally, we offered our opinion about the challenges and weaknesses of the selected papers. RESULTS: By our search, 1,177 manuscripts were found (485 in PubMed, 343 in Embase, and 349 in Scopus). After the implementation of inclusion and exclusion criteria, 18 papers remained for the final analysis by RQS. The total RQS score ranged from 26 (59% of maximum possible score) to 43 (97% of maximum possible score) with a mean of 33.5 (76% of maximum possible score). CONCLUSION: The current studies are promising but very heterogeneous in design with high variation in the radiomics software, the number of extracted features, the number of selected features, and machine learning models. All of the studies were retrospective in design; many are based on small datasets and/or suffer from class imbalance and lack of external validation data-sets.

Susceptibility-Weighted Imaging in Neurodegenerative Disorders: A Review.

As human life expectancy increases, there is an increased prevalence of neurodegenerative disorders and dementia. There are many ongoing research trials for early diagnosis and management of dementia, and neuroimaging is a critical part of such studies. However, conventional neuroimaging often fails to provide enough diagnostic findings in patients with neurodegenerative disorders. In this context, different MRI sequences are currently under investigation to facilitate the accurate diagnosis of such disorders. Susceptibility-weighted imaging (SWI) is an innovative MRI technique that utilizes "magnitude" and "phase" images to produce an image contrast that is sensitive for the detection of susceptibility differences of the tissues. As many neurodegenerative disorders are associated with accelerated iron deposition and/or microhemorrhages in different parts of the brain, SWI can be applied to detect these diagnostic clues. For instance, in cerebral amyloid angiopathy, SWI can demonstrate cortical microhemorrhages, which are predominantly in the frontal and parietal regions. Or in Parkinson disease, abnormal swallow-tail sign on high-resolution SWI is highly diagnostic. Also, SWI is a useful sequence to detect the low signal intensity of precentral cortices in patients with amyotrophic lateral sclerosis. Being familiar with SWI findings in neurodegenerative disorders is critical for an accurate diagnosis. In this paper, the authors review the technical parameters of SWI, physiologic, and pathologic iron deposition in the brain, and the role of SWI in the evaluation of neurodegenerative disorders in daily practice.

Emerging Applications of Radiomics in Neurological Disorders: A Review.

Radiomics has achieved significant momentum in radiology research and can reveal image information invisible to radiologists' eyes. Radiomics first evolved for oncologic imaging. Oncologic applications (histopathology, tumor grading, gene mutation analysis, patient survival, and treatment response prediction) of radiomics are widespread. However, it is not limited to oncologic analysis, and any digital medical images can benefit from radiomics analysis. This article reviews the current literature on radiomics in non-oncologic, neurological disorders including ischemic strokes, hemorrhagic stroke, cerebral aneurysms, and demyelinating disorders.

How may Doppler indices help in the differentiation of obstructive from nonobstructive hydronephrosis?

BACKGROUND: We assess the potency of different Doppler indices in the differentiation of obstructive and nonobstructive hydronephrosis. MATERIALS AND METHODS: In this study, infants and children who were referred for the evaluation of unilateral hydronephrosis were enrolled. Ultrasonography for the assessment of the degree of hydronephrosis and a voiding cystourethrogram for the exclusion of vesicoureteral reflux was performed. Then, Doppler ultrasonography was done for both kidneys of each patient using four classic Doppler indices as well as the difference (delta) of each index between to kidneys. Diuretic renography with 99 mTc-ethylene dicysteine (99 mTc-EC) was performed for each patient. RESULTS: Thirty-nine patients met the inclusion criteria. After diuretic renography, 29 (74.35%) patients had shown a nonobstructive pattern, and ten (25.65%) patients had a partial (intermediate) or complete obstruction. Using receiver operating characteristic (ROC) curve, none of the classic indices of Doppler duplex (i.e., resistive index [RI], resistance index, end diastolic velocity, and peak systolic velocity) had the ability to make a difference between obstructive and nonobstructive hydronephrosis. However, by calculating the difference (delta) of these indices between two kidneys of each patient, delta RI could differentiate the nonobstructive condition, significantly (P = 0.006). A cutoff value of 0.055 has 60% sensitivity and 82.8% specificity. The area under the ROC curve for delta RI is 0.795 (standard error: 0.086, 95% confidence interval [CI]: 0.626, 0.964). Furthermore, RI ratio between two kidneys of each patient could differentiate the nonobstructive condition, significantly (P = 0.012). A cutoff point of 1.075 has 70% sensitivity and 82.8% specificity. The area under the ROC curve for RI ratio was 0.769 (standard error: 0.104, 95% CI: 0.565, 0.973). CONCLUSION: This study shows that RI ratio and delta RI with a high specificity could differentiate nonobstructive hydronephrosis and therefore it is a promising way to use especially in the follow-up of children with hydronephrosis.

Is there any Correlation between Magnetic Resonance Imaging Features of Breast Lesions of BIRADS Category 4 with Histopathologic Results?

BACKGROUND: To evaluate the correlation of magnetic resonance imaging (MRI) features of breast lesions of Breast Imaging Reporting and Database System (BI-RADS) category 4 with histopathologic results. MATERIALS AND METHODS: In a prospective study between December 2013 and April 2015, patients with suspicious mammographic and/or ultrasound findings referred for Breast MRI were evaluated. Patients with lesions of BI-RADS category 4 were enrolled with a written informed consent. In each patient, mass lesion (ML) or nonmass lesion (NML) was determined, and different characteristics of the lesions were recorded. A follow-up program was taken with mean 3-12 months. Patients who underwent core needle biopsy or open biopsy were summoned. RESULTS: Seventy-eight females aged 24-67 years (mean 43.1 ± 8.8) met the inclusion criteria and had adequate samples for histopathologic study. Twenty-nine (37.2%) patients had ML and 49 (62.8%) patients had NML. Tissue sampling in 63 (80.7%) patients was through core needle biopsy and in 15 (19.2%) patients through surgery. A wide spectrum of benign and malignant pathologic diagnoses was seen. In statistical analysis, none of the MRI features has a significant correlation with any specific histopathologic diagnosis (P = 0.185). However, the relation between the MRI category (ML or NML) and pathology results was significant at level of 0.1 (P = 0.06). CONCLUSION: This study showed that a wide spectrum of histopathologic results is seen in BI-RADS category 4. However, in this sample volume, none of the MRI features in this BI-RADS category has a significant correlation with any specific histopathologic diagnosis.

Resolution of aspergillosis in neuroimaging of an immunocompromised patient with pulmonary and cerebral lesions.

Central nervous system (CNS) aspergillosis is uncommon and considered the most lethal form of aspergillosis. Indeed, current therapeutic strategies such as combination antifungal regimen, neurosurgical resection of infected tissue, and removal of infection source fail to improve the unsatisfactory prognosis of CNS aspergillosis in the majority of the patients. The authors describe a case of chronic pulmonary aspergillosis with concomitant CNS lesions that dramatically responded to antifungal therapy and the CNS lesions resolved in follow-up imaging.

Computed tomography-guided percutaneous core needle biopsy for diagnosis of mediastinal mass lesions: Experience with 110 cases in two university hospitals in Isfahan, Iran.

BACKGROUND: Computed tomography-guided percutaneous core needle biopsy (PCNB) is a diagnostic technique for initial assessment of mediastinal mass lesions. This study was conducted to evaluate its diagnostic yield and its complication rate. MATERIALS AND METHODS: We reviewed the records of CT-guided PCNB in 110 patients with mediastinal mass lesions performed in Kashani and Alzahra Hospitals, Isfahan, from 2006 to 2012. Gender, age at biopsy, size, and anatomic location of the lesion, number of passes, site of approach, complications, and final diagnosis were extracted. RESULTS: Our series encompasses 52 (47.2%) females and 58 (52/7%) males with mean age of 41 ± 8 years. The most common site of involvement was the anterior mediastinum (91.8% of cases). An average of 3/5 passes per patient has been taken for tissue sampling. Parasternal site was the most frequent approach taken for PCNB (in 78.1% of cases). Diagnostic tissue was obtained in 99 (90%) biopsies while, in 11 (10%) cases, specimen materials were inadequate. Lymphoma (49.5%) and bronchogenic carcinoma (33.3%) were the most frequent lesions in our series. The overall complication rate was 17.2% from which 10.9% was pneumothorax, 5.4% was hemoptysis, and 0.9% was vasovagal reflex. CONCLUSION: CT-guided PCNB is a safe and reliable procedure that can provide a precise diagnosis for patients with both benign and malignant mediastinal masses, and it is considered the preferred first diagnostic procedure use for this purpose.

Two unusual sites of cystic lymphangioma in a child: A report of imaging profile with surgical and histopathologic findings.

Cystic lymphangioma (CL) is a benign lymphatic malformation mostly seen in the head and neck of neonates and infants. Abdominal CL is an unusual entity which may present in omentum, mesentery, abdominal wall, or solid organs. The authors present an unusual case with two separate abdominal cystic lymphangiomas.

Usefulness of combination of grey-scale and color Doppler ultrasound findings in the diagnosis of ulnar nerve entrapment syndrome.

BACKGROUND: Ulnar nerve entrapment (UNE) has been diagnosed with clinical examination and electrodiagnostic studies. This study was designed to determine the value of a combination of grey-scale and color Doppler ultrasound findings in the diagnosis of patients with UNE. MATERIALS AND METHODS: During May to August 2013 41 patients with UNE (proven by electrodiagnostic studies) and 44 healthy volunteers were evaluated by ultrasound study. Three cross-sectional area (CSA) of ulnar nerve around cubital fossa was determined and measured in both groups. The maximum and minimum diameter of ulnar nerve was measured for calculating flattening ratio index (FRI). Vascularity of ulnar nerve around cubital fossa was also examined in proper color Doppler setting. RESULTS: The mean CSA of nerve at all proximal, middle and distal levels were greater in patients with UNE than in controls (P = 0.02, <0.001 and 0.34 respectively). A cut-off point of 10.5 mm(2) for CSA (in the level of the cubital fossa) yielded a sensitivity and specificity of 92.7% and 93.2%, respectively. Mean FRI was 3.1 ± 0.6 in patients with UNE group and 1.4 ± 0.2 in the control group with a significant difference (P < 0.001). FRI with cutoff point 2.15 has been shown as an important parameter for the detection of UNE. The vascularity in UNE has a sensitivity and specificity of 66% and 93.2%, respectively, and has a higher probability of being positive in severe UNE. CONCLUSION: Combination of grey-scale and color Doppler ultrasound may provide valuable diagnostic criteria and severity assessment of UNE.

Prevalence and Prognosis of Cerebrovascular Accidents and its Subtypes Among Patients with Systemic Lupus Erythematosus in Isfahan, Iran: A Hospital Clinic-based Study.

BACKGROUND: The aim of the present study was to determine the prevalence and prognosis of cerebrovascular accident (CVA) and its subtypes among Iranian patients with systemic lupus erythematosus (SLE). METHODS: In a cross-sectional study, medical records of 575 SLE patients were reviewed. The patients developing CVA in their course of disease were extracted. In these patients, data about demographic features, lupus anti bodies, duration of the disease until CVA, CVA manifestation(s) and follow-up duration were gathered. In the next step, patients with any kinds of CVA were summoned to Neurology clinic to identify the grade of disability in each patient with CVA. RESULTS: We identified 38 patients with CVA of which 6 (15.8%) were men and 32 (84.2%) were women. The most common subtype of CVA was small vessels thrombosis (21.05%) among the study patients and hemi paresis was the most prevalent initial presentation (39.47%). In 11 (28.9%) patients, SLE was initiated with CVA and in 3 (7.9%) patients CVA had happened in the 1(st) year of SLE. Anti-phospholipid antibodies (APLA) were positive in 29 (76.3%) patients. Mean modified Rankin Scale in patient with positive and negative serology for APLA was 0.93 ± 1.11 and 0.22 ± 0.66 respectively (P = 0.006). CONCLUSIONS: Our study shows that 6.6% of Iranian SLE patients have CVA during their course of the disease. Small vessels thrombosis is the most common CVA subtype and hemi paresis is the most prevalent initial presentation. Moreover, we showed that the prognosis of CVA in Iranian SLE patients is not unfavorable.

Recurrent acute pancreatitis and cholangitis in a patient with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder associated with multiple cyst formation in the different organs. Development of pancreatic cyst in ADPKD is often asymptomatic and is associated with no complication. A 38-year-old man with ADPKD was presented with six episodes of acute pancreatitis and two episodes of cholangitis in a period of 12 months. Various imaging studies revealed multiple renal, hepatic and pancreatic cysts, mild ectasia of pancreatic duct, dilation of biliary system and absence of biliary stone. He was managed with conservative treatment for each attack. ADPKD should be considered as a potential risk factor for recurrent acute and/or chronic pancreatitis and cholangitis.