The role of imaging in the management of non-traumatic subarachnoid hemorrhage: a practical review.

The purpose of this review is to understand the role of imaging in the diagnosis and management of non-traumatic subarachnoid hemorrhage (SAH). SAH is a life-threatening emergency and a relatively common entity, the most common etiology being ruptured aneurysms. Multiple conundrums exist in literature at various steps of its imaging workup: diagnosis, management, and follow-up. We target our review to highlight the most effective practice and suggest efficient workup plans based on literature search, and describe in detail the clinical diagnostic and prognostic scales, role of CT scan, lumbar puncture, and MR, including angiography in the diagnosis and workup of SAH and its complications, and try to simplify the conundrums. Practical knowledge of imaging workup of SAH can help guide correct management of these patients, so as to reduce morbidity and mortality without resource overutilization.

Limited positive predictive value of diffusion tensor tractography in determining clinically relevant white matter damage in brain stem cavernous malformations: A retrospective study in a single center surgical cohort.

PURPOSE: Diffusion tensor tractography (DTT) might reflect the postoperative clinical outcome of the patients with brain stem (BS) tumors correlating well with the neurological symptoms, but cavernous malformation (CM) is a hemorrhagic tumor prone to artifacts that may limit DTT. We set out to determine the correlation of DTT findings with the neurological examination before and after surgical resection in patients with BSCMs. MATERIALS AND METHODS: DTT findings were evaluated bilaterally for fiber tract displacement or deviation, deformation and interruption in every patient before and after the surgery. Neurological examination was performed at admission, discharge and outpatient follow-up visit. The sensitivity, specificity, positive and negative predictive values of DTT were calculated both pre- and post-operatively. RESULTS: There were 25 patients (9 men 16 women) with a mean age of 39.5±13.9 years. The mean size of the CMs was 6909±8374mm3 (range: 180-38,220mm3) The mean follow-up time was 42.7±23.2 months (range: 8 to 112 months). Preoperatively, the sensitivity, specificity, positive and negative predictive values of DTT for corticospinal tracts (CST) and medial lemnisci (ML) were 100%, 60%, 38.4%, 100% and 87.5%, 11.7%, 31.8%, 66.6%, respectively. Postoperatively, the sensitivity, specificity, positive and negative predictive values of DTT for CSTs and ML were 100%, 64.7%, 40%, 100% and 100%, 0%, 33.3%, 66.6%, respectively. CONCLUSION: Positive findings on DTT such as fiber tract deviation, deformation, disruption or interruption should be taken cautiously before drawing conclusions of a clinically relevant damage of white matter tracts.

Anatomical landmarks for cochlear implantation in ossified cochleas.

PURPOSE: In this study, we aimed to introduce the facial nerve as a new anatomical landmark which can be used in ossified cochleas during cochlear implantation. We also set out to define a safe line to preserve the internal auditory canal (IAC) while drilling the basal turn of the cochlea. METHODS: Thirty patients who had temporal computed tomography (CT) were studied. The distances from the facial nerve and the round window to the IAC, carotid artery, and jugular bulb were measured in the reformatted CT images. We have created a line in the direction of the stapedial tendon from the round window to the IAC and called it ROWIAC (Round window-IAC) line. We have investigated whether this line intersects the IAC and measured the distances from this line to the IAC. RESULTS: Fifty-four temporal CT scans were included to the study. The mean distances from the facial nerve to the IAC, carotid artery, and jugular bulb were 8.8 ± 0.9, 15.0 ± 2.0, and 12.2 ± 2.9 mm, respectively. The mean distances from the round window to these structures were 3.8 ± 0.7, 9.4 ± 2.2, and 8.3 ± 2.9 mm, respectively. ROWIAC line did not intersect the IAC in any of the patients. The mean distance between this line and the IAC was 0.8 ± 0.4 mm. CONCLUSION: We propose that facial nerve and ROWIAC line can be used as potential landmarks during cochlear implantation in ossified cochleas to protect the adjacent neurovascular structures.

Safety of transarterial radioembolization with Yttrium-90 glass microspheres without cystic artery occlusion.

PURPOSE: To assess radiation-induced cholecystitis in cases of cystic artery origin nearby the treatment zone for transarterial radioembolization (TARE) treatment. MATERIALS AND METHODS: Patients with primary or secondary malignant liver tumors treated with TARE, in whom cystic artery was located in the surrounding area of the treatment zone on 99m-technetium-MAA angiograms, were included in this study. Whole liver dose, tumor dose and healthy injected liver dose, lung dose and if applicable the gallbladder dose were all calculated by using the Medical Internal Radiation Dose (MIRD) formula from SPECT-CT images. Qualitative and quantitative assessment of the gallbladder was performed on SPECT-CT. The observed adverse events were classified according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE v5.0). RESULTS: A total of 34 TARE procedures from 29 patients (18 men and 11 women), with a mean age of 65 ± 13.3 years meeting the inclusion criteria, were involved in the current study. The mean tumor dose, healthy injected liver dose, healthy whole liver dose and gallbladder dose were 204.9 ± 66.8 Gy, 70.5 ± 15.7 Gy, 31.1 ± 12.7 Gy and 96.4 ± 53.4 Gy, respectively. The mean follow-up period was 14 ± 5.2 months. Qualitative assessment revealed gallbladder radioactivity on SPECT-CT in 11 (32.3%) patients with six mild and five moderate-severe radioactivities. There were no detected grade 2 or 3 adverse events. CONCLUSION: TARE is safely performed without cystic artery embolization when its origin is close to the treatment area.

Accuracy of routine fat-suppressed FLAIR and diffusion-weighted images in detecting clinically evident acute optic neuritis.

BACKGROUND: Contrast-enhanced, fat-suppressed T1-weighted imaging (CET1WI) magnetic resonance imaging (MRI) is quite sensitive in detecting acute optic neuritis (ON), but ON remains a clinical diagnosis. MRI is indicated to evaluate demyelinating brain lesions rather than the optic nerves, while "routine" brain protocols typically include axial FLAIR and DWI. PURPOSE: To evaluate the accuracy of axial, fat-suppressed FLAIR and DWI sequences used for our routine brain imaging in detecting acute ON, as compared to CET1WI and the clinical diagnosis. MATERIAL AND METHODS: The clinical data and MRI examinations were retrospectively reviewed of 60 patients presenting to a neuro-ophthalmologist for various visual symptoms. Each patient underwent dedicated neuro-ophthalmologic examination, with axial 5 mm fat-suppressed FLAIR and DWI (part of "routine" brain MRI protocol), as well as 3 mm axial and coronal fat-suppressed CET1WI (part of dedicated orbit MRI protocol). Two neuroradiologists independently evaluated FLAIR and DWI, while CET1WI was reviewed by consensus. RESULTS: Thirty-one patients were clinically positive, 29 negative for ON (total = 34 positive and 86 negative nerves). The sensitivities of FLAIR, DWI, and CET1WI for ON were 75.7-77.3%, 77.3%, and 89.5%, respectively; the specificities were 90.5-93.5%, 80.4-82.7%, and 86.0%, respectively; the accuracies were 85.7-88.2%, 79.5-81.1%, and 87.0%, respectively. Inter-observer kappa was 0.783 for FLAIR, and 0.605 for DWI; intra-observer kappa was 0.746-0.816 for FLAIR, and 0.674-0.699 for DWI (each P < 0.0001). CONCLUSION: Being more specific, but not as sensitive, as dedicated CET1WI in acute ON, axial fat-suppressed FLAIR likely has additional value in evaluating for acute ON in "routine" brain MR protocols evaluating for demyelinating disease, while DWI may be hampered by artifacts.

Prevalence and Patterns of Resuscitation-Associated Injury Detected by Head-to-Pelvis Computed Tomography After Successful Out-of-Hospital Cardiac Arrest Resuscitation.

Background Patients resuscitated from out-of-hospital circulatory arrest (OHCA) frequently have cardiopulmonary resuscitation injuries identifiable by computed tomography, although the prevalence, types of injury, and effects on clinical outcomes are poorly characterized. Methods and Results We assessed the prevalence of resuscitation-associated injuries in a prospective, observational study of a head-to-pelvis sudden-death computed tomography scan within 6 hours of successful OHCA resuscitation. Primary outcomes included total injuries and time-critical injuries (such as organ laceration). Exploratory outcomes were injury associations with mechanical cardiopulmonary resuscitation and survival to discharge. Among 104 patients with OHCA (age 56±15 years, 30% women), 58% had bystander cardiopulmonary resuscitation, and total cardiopulmonary resuscitation time was 15±11 minutes. The prevalence of resuscitation-associated injury was high (81%), including 15 patients (14%) with time-critical findings. Patients with resuscitation injury were older (58±15 versus 46±13 years; P<0.001), but had otherwise similar baseline characteristics and survival compared with those without. Mechanical chest compression systems (27%) had more frequent sternal fractures (36% versus 12%; P=0.009), including displaced fractures (18% versus 1%; P=0.005), but no difference in survival (46% versus 41%; P=0.66). Conclusions In patients resuscitated from OHCA, head-to-pelvis sudden-death computed tomography identified resuscitation injuries in most patients, with nearly 1 in 7 with time-critical complications, and one-half with extensive rib-cage injuries. These data suggest that sudden-death computed tomography may have additional diagnostic utility and treatment implications beyond evaluating causes of OHCA. These important findings need to also be taken in context of the certain fatal outcome without resuscitation efforts. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03111043.

Causes of misinterpretation of cross-sectional imaging studies for dissection of the craniocervical arteries.

OBJECTIVE: This review presents some of the more common causes of false-positive and false-negative interpretations of cross-sectional imaging studies showing, or designed to show, dissection of the carotid or vertebral arteries. CONCLUSION: Dissection of the craniocervical arteries is a diagnosis that can be very difficult on cross-sectional imaging studies such as CT angiography, MRI, and MR angiography.

Diffusion-tensor imaging assessment of white matter maturation in childhood and adolescence.

OBJECTIVE: The purpose of this study was to test a first hypothesis that fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values continue to change in late childhood and adolescence and a second hypothesis that less mature white matter (WM) regions have a higher rate of change than WM regions that are relatively more mature. SUBJECTS AND METHODS: Eighty-seven healthy children (50 girls, 37 boys; mean age, 11.2 ± 3.6 years; range, 4.2-17.7 years) underwent six-direction diffusion-tensor imaging with a 3-T MRI system. Three neuroradiologists independently drew regions of interest in 10 WM regions and measured FA and ADC values. To test the first hypothesis, we correlated these values with subject age by linear regression analysis (p < 0.05). To test the second hypothesis, we determined whether regions with lower FA and higher ADC in the 4- to 7-year old group had a higher slope of FA increase and ADC decrease over the entire age range. For this assessment, we used linear regression analysis (p < 0.05) and curve fitting. RESULTS: In the test of the first hypothesis, increases in FA with age were noted in all WM regions and were statistically significant in six regions. Decreases in ADC values with age were noted in all brain regions except the genu of the corpus callosum. In all other regions except the splenium of the corpus callosum, the decreases were statistically significant. In the test of the second hypothesis, the relation between FA in the 4- to 7-year-old subjects and the FA increase in the entire sample was best described with a linear equation. The rate of age-related FA increase tended to be greater with lower initial FA (r = -0.384, p = 0.271). The relation between ADC in the 4- to 7-year-old subjects and ADC decrease in the entire population was best described with a second-order equation. The rate of age-related ADC decrease tended to be greater with higher initial ADC (r = 0.846, p = 0.001). For ADC values of 100 or less at age 4-7 years, the rate of ADC change with age tended to be decrease as initial ADC increased. CONCLUSION: In general, both hypotheses were verified. Overall, FA values continue to increase and ADC values continue to decrease during childhood and adolescence. The most rapid changes were found in WM regions that were least mature in the first few years of the study period.

Comparison of time-of-flight MR angiography and intracranial vessel wall MRI for luminal measurements relative to CT angiography.

OBJECTIVE: To assess whether intracranial vessel wall (IVW) MRI luminal measurements are more accurate than non-contrast 3D-TOF-MRA measurements for intracranial atherosclerotic stenosis, relative to CTA. METHODS: Consecutive patients with non-calcified intracranial atherosclerotic stenosis seen on CTA, who had non-contrast 3D-TOF-MRA and IVW performed between 1 January 2013 and 20 April 2014 were selected, and images with stenosis were pre-selected by a single independent rater. The pre-selected CTA, MRA, and IVW (T1-weighted) images were then reviewed by two independent raters blinded to the other measurements in random order. Measurements were made in a plane perpendicular to the lumen on each modality. MRA and IVW measurements were compared to CTA, to determine which more accurately matched the degree of stenosis. RESULTS: 18 patients with 33 intracranial atherosclerotic stenoses were included. Relative to CTA, IVW had 40% less variance than MRA (p = .004). IVW had a significantly higher concordance correlation coefficient (CCC) relative to CTA than MRA (.87 vs .68, p = .002). IVW and MRA did not have significant bias relative to CTA, however, 8/33 lesions showed >20% overestimation of the degree of stenosis on MRA, compared to 1/33 for IVW. CCC between raters were 0.84 (95% CI 0.67-0.93) for CTA, 0.83 (0.67-0.93) for TOF-MRA, and 0.85 (0.71-0.94) for IVW. For stenosis >50% sensitivity was 82% for IVW and 64% for MRA, while specificity was 73% for both. CONCLUSION: IVW provides more accurate stenosis measurements than MRA when compared to CTA. ADVANCES IN KNOWLEDGE: Considering higher stenosis measurement accuracy of IVW, it can be more reliably used for quantitative evaluation relative to MRA.

Ultrasonographic evaluation of disc displacement of the temporomandibular joint compared with magnetic resonance imaging.

PURPOSE: We compared high-resolution ultrasonography with magnetic resonance imaging (MRI), as the gold standard, to evaluate lateral and anterior capsule-condyle distances to detect disc displacement of the temporomandibular joint. MATERIALS AND METHODS: This study included 28 patients (19 female and 9 male; age range, 16-51 years; mean age, 32.82 years), and in total, 56 joints were assessed with ultrasonography and MRI. Measurements were obtained for anterior capsule-condyle and lateral capsule-condyle distances in both open- and closed-mouth positions with high-resolution ultrasonography. These findings were also compared with those of MRI taken as reference. Receiver operating characteristic curve analysis was performed to assess our results. We assessed sensitivities, specificities, accuracies, and positive and negative predictive values for both open- and closed-mouth positions. RESULTS: Diagnostic accuracy of ultrasonographic anterior capsule-condyle distance in the closed-mouth position to detect MRI-positive disc displacement (area under receiver operating characteristic curve, 0.689; P = .015) was the highest. CONCLUSIONS: The measurement of the distance between the most anterior point of the articular capsule and the most anterior point of the condyle can be used to assess disc displacement in diseased joints. However, it is necessary to determine the most accurate threshold value and to set cutoff values. These findings need to be confirmed by further research in a large number of patients to test the interexaminer agreement and the reproducibility of this method.

Frequency of various brain parenchymal findings of early cerebral ischemia on unenhanced CT scans.

The purpose of the study was to determine the frequency of various unenhanced computed tomography (CT) findings of early cerebral ischemia within brain parenchyma, which could be useful to the radiologist who is interpreting CT studies by indicating the CT finding that is most likely to be present in early cerebral ischemia. We analyzed articles reporting the use of unenhanced CT in acute cerebral ischemia over the period 1976-2009 for frequency of the following brain parenchyma signs: loss of insular ribbon, obscuration of lentiform nucleus, sulcal effacement, and parenchymal hypodensity. We recorded data for the 2-, 3-, 6-, and 12-h intervals after symptom onset from various studies and (1) calculated percent of time intervals in which >50% of patients exhibited the finding in any study and (2) pooled results for patients reported as having a specific CT finding during a specific time interval. We hypothesized that CT findings indicating brain swelling, which would be expected to be a relatively late phenomenon, would be detected at a lower rate in the first 6 h than changes of decreased density of brain tissue and increased density of arteries. The loss of insular ribbon sign (83% of time intervals reported) and obscuration of lentiform nucleus sign (75%) were the most common signs present in >50% patients in a time interval in any article. Pooled results showed that the two most common findings in the first few hours were loss of insular ribbon (70% at 2 h; 77% at 3 h) and obscuration of lentiform nucleus (60% at 2 h; 82% at 3 h). At 6 h, parenchymal hypodensity (53%), loss of insular ribbon (46%), and obscuration of lentiform nucleus (46%) were most common, which validated our hypothesis. At 12 h, loss of insular ribbon (65%) and sulcal effacement (63%) were most common. Loss of insular ribbon and obscuration of lentiform nucleus appear to be the most common signs of early cerebral ischemia identified on unenhanced CT.

Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature.

OBJECTIVE: Initial assessment of patients with suspected dissection of the carotid or vertebral arteries typically is made by MRI, alone or in combination with MR angiography (MRA) or CT angiography (CTA). We reviewed the medical literature to determine, based on test performance characteristics such as sensitivity, specificity, positive predictive value, and negative predictive value, whether evidence could be found to support routine use of one imaging technique over the other for assessment of suspected dissection. CONCLUSION: Test characteristics for MR techniques such as MRI and MRA were relatively similar to those for CTA in diagnosis of carotid and vertebral artery dissection.

Intra-familial incidence and characteristics of hot water epilepsy.

OBJECTIVE: To assess the clinical features of several members of the same family diagnosed with both hot water epilepsy (HWE) and cerebral lesions. METHODS: Age at onset and types of seizure, precipitating factors, EEG findings, and neuroimages were evaluated. RESULTS: The family consisted of six generations, including one consanguineous parent. Of eight family members diagnosed with epilepsy, seven suffered from HWE. Age at onset of seizures ranged within childhood. Seven patients with HWE experienced complex partial seizures, with or without secondary generalization; one experienced simple partial seizures as well as complex partial seizures. Three patients experienced spontaneous seizures as well as HWE. Interictal EEG revealed abnormalities in two patients. Magnetic resonance imaging revealed cerebral lesions in one patient, probably attributable to ischemic changes. Magnetic resonance images were consistent with findings of ischemic gliosis in two patients, and either demyelinating or ischemic gliosis in one patient. CONCLUSIONS: Descriptions of HWE families with different ethnic backgrounds may permit more definite conclusions regarding the mechanisms epileptogenesis, and the genetic defects that underlie this disease.

Fast kilovoltage-switching dual-energy CT offering lower x-ray dose than single-energy CT for the chest: a quantitative and qualitative comparison study of the two methods of acquisition.

PURPOSE: We aimed to compare the size-specific dose estimates (SSDE), computed tomography (CT) dose indices and image quality parameters of the chest CTs obtained with fast kilovoltage-switching (FKS) dual-energy (DE) CT versus those with single-energy (SE) CT. METHODS: Patients who had chest SECT within the last 6 months were prospectively scanned with chest FKS-DECT. Quantitative comparison was made by calculating the mean SSDE, CTDIvol, contrast, noise, contrast-to-noise ratio (CNR), and signal-to-noise ratio (SNR) for both acquisitions. Two radiologists evaluated the chest SECT and DECT images qualitatively blinded to the technique used. The paired Student's t test was utilized for comparing the quantitative and qualitative data. Inter- and intraobserver agreement were also assessed. RESULTS: A total of 42 patients were included. The mean SSDE, CTDIvol, contrast, noise, CNR, and SNR for SECT versus DECT were 12.7±2.2 mGy vs. 9.3±1.2 mGy (P = 0.001), 10.9±2.4 mGy vs. 8±1.2 mGy (P < 0.001), 211.9±44.7 vs. 216.3±59 (P = 0.350), 12.9±2.4 vs. 13.9±3.7 (P = 0.086), 13.5±5.2 vs. 13.3±8.4 (P = 0.548) and 12±3.5 vs. 11.5±3.4 (P = 0.774), respectively. Interobserver reproducibility was high for contrast, noise, CNR, and SNR (ICC = 0.89, 0.85, 0.93, and 0.82, respectively; all P < 0.05). Intraobserver reproducibility was high for contrast, noise, CNR, and SNR (ICC = 0.80, 0.77, 0.85, and 0.88, respectively; all P < 0.05). CONCLUSION: The mean SSDE of the chest CTs obtained with FKS-DECT were 26.8% lower than those with SECT with significant difference for the objective assessment and there was no significant difference for the subjective assessment of the image qualities, in this series.

Unilateral isolated incus agenesis: detection by virtual endoscopy.

We report the first case of unilateral incus agenesis in the literature. Preoperative diagnosis by virtual endoscopy further enhances the significance of this case. We present thin-section temporal bone computed tomographic images and 3-dimensional reconstructed views which were all correlated with intraoperative findings. The patient was successfully treated with an ossicular prosthesis replacement.

Aripiprazole for the Treatment of Inappropriate Sexual Behavior: Case Report of an Alzheimer's Disease Patient Known as Heterosexual with Recently Shifted Sexual Orientation to Same Gender.

Although inappropriate sexual behavior in dementia is not common, it can be extremely troublesome for healthcare professionals and caregivers as well as patients themselves. There is paucity of data in the literature for the management of these behaviors, but the limited available data suggest efficiency of some commonly used treatment modalities. Herein, we present a 74-year old Alzheimer's disease (AD) patient, known to be heterosexual throughout her past life, presenting with a recent display of same-sex inappropriate sexual behavior six years after the initial diagnosis of her disease. This new clinical picture of hypersexuality responded well to aripiprazole and her symptoms gradually diminished and eventually disappeared after onset of medication. This report also constitutes the first reported case of an AD patient in the published literature presenting with hypersexuality of shifted sexual orientation during the course of the disease.

Intermediate catheter placement distal to the cerebral aneurysm during flow diversion embolization with the Surpass device.

PURPOSE: We present the preliminary angiographic and clinical results of the combined utilization of an AXS Catalyst 5 (Cat5) distal access catheter and a Surpass flow diverter (SFD) for the endovascular treatment of intracranial aneurysms. MATERIALS AND METHODS: Interventional neuroradiology case records were evaluated retrospectively to identify patients treated with an SFD in combination with Cat5. Demographic data, technical success, location of the catheter tip, aneurysm occlusion rate, and procedure-related morbidity and mortality were noted. RESULTS: The analysis yielded 24 patients with 25 aneurysms with a mean age of 52.3±19.7 years. The mean aneurysm diameter was 15.7±8.8 mm. Twenty-one were anterior circulation (seven supraclinoid, one middle cerebral, one anterior choroidal and 12 petrocavernous) and four were posterior circulation (three basilar tip, one posterior inferior cerebellar) aneurysms. Only two of these aneurysms were re-treatments for recurrences. For SFD deployment, the distal tip of Cat5 was placed intradurally and at, or distal to, M1 segment in 88% and 48% of patients, respectively. Aneurysms were bypassed with Cat5 in 80% of the procedures. In one patient, flow diversion was abandoned totally due to arterial tortuosity. With the exclusion of this patient, the technical success rate was 91.7%. There was no permanent procedure-related morbidity or mortality. Of the 22 aneurysms treated successfully with the Surpass device, 20 had imaging follow-up at 6.3±3.8 months and 95% were totally occluded. CONCLUSION: The Cat5 catheter, which was manufactured for the navigation of large-bore stent-like devices, is a useful adjunct to the Surpass device and allowed us to deploy the device safely.

Unregistered subtracted CT angiography for the visualization of intracranial arteries at or near the skull base: preliminary experience.

PURPOSE: Restrictions with computed tomography angiography (CTA) regarding the visualization of arteries near the skull base are well known. Today, the gold standard for overcoming this is the matched mask bone elimination method. Worldwide use of this method is limited since it requires advanced imaging physics and software. A more simple method was introduced recently that avoided motion artifacts significantly by restraining the patient's head with a vacuum-type head holder. The purpose of this study was to investigate the feasibility of using unregistered subtracted CTA without such head-holding methods. MATERIALS AND METHODS: Of the 42 patients that underwent subtracted CTA, 39 were recruited for this study. Two patients were excluded due to agitation during examination and one due to artifacts of an embolized aneurysm. All the examinations were performed in an 8-channel multidetector CT suite. After performing a non-contrast low-dose CT examination, CTA was carried out using the same scan planes as on the scout images. Images were transferred to a workstation and subtraction was performed. Hard-copy images through identical locations were reviewed by 2 observers, a radiologist and a clinician (neurologist), and visualization of the internal carotid artery and posterior artery systems were scored. Data were analyzed using the Wilcoxon signed-rank test. RESULTS: Significant statistical differences, in favor of subtracted images, were noted in both observers' scores, both for the internal carotid artery and posterior system arteries. The differences in the clinician's scores were more prominent than that of radiologist's. CONCLUSION: These results are promising for the expanded use of the subtraction method, especially in radiology departments that lack the staff and equipment for registered methods.

Encephalocraniocutaneous Lipomatosis: Haberland Syndrome.

BACKGROUND Encephalocraniocutaneous lipomatosis (ECCL) was first announced as a new type of ectomesodermal dysgenesis in 1970 by Haberland and Perou. ECCL was first described in 1970, and approximately 60 cases have been reported since then. The classic triad of ECCL are skin, ocular, and central nervous system involvement, including conditions such as unilateral porencephalic cyst, ipsilateral lipomatous hamartoma of the scalp-eyelids-eye globe, cortical atrophy, cranial asymmetry, developmental delay, seizures, mental retardation, and spasticity of the contralateral limbs. The dermatological hallmark is a hairless fatty tissue nevus of the scalp called nevus psiloliparus. CASE REPORT An 11-year-old right-handed boy, born at full term, was referred to our clinic. His family had no consanguinity or history of neurocutaneous disease. The patient's physical examination revealed a large hairless lesion on the right frontoparietal scalp called nevus psiloliparus. Beginning from the birth, a dermolipoma (an uncommon benign tumor) was reported to have occurred on the conjunctiva, mostly ipsilateral in his right eye and present on the ipsilateral side of the neurological abnormalities shown on magnetic resonance imaging and computed tomography. The patient had muscle weakness in left upper and lower extremities. He had a mild form of mental retardation. CONCLUSIONS There is no specific treatment for ECCL. Management of ECCL is usually symptomatic. Surgical correction of a cutaneous lesion can be performed for cosmetic improvement. An early diagnosis of ECCL allows for early symptom treatment and improved patient quality of life.