[An update on adenomyosis and implantation]. / Adénomyose et implantation : mise au point.

Adenomyosis is an enigmatic disease whose impact on implantation and fertility outcome is still controversial. A negative effect on IVF outcome was already observed, but it is mainly explained by an increase in early spontaneous miscarriages. We reviewed scientific data in order to bring relevant information about adenomyosis and endometrial receptivity for patient counselling and to precise if screening of adenomyosis is indicated before IVF treatment.

Optic tract compression from dolichoectatic basilar artery.

PURPOSE: To report a case of optic tract compression caused by a dolichoectatic basilar artery. DESIGN: Observational case report. METHODS: A 74-year-old man with progressive loss of vision over 13 years and no other neurologic signs or symptoms was found to have bilateral optic nerve head pallor and a left homonymous hemianopia. RESULTS: Magnetic resonance imaging and angiography revealed a severe dolichoectatic basilar artery compressing the right optic tract. CONCLUSION: Basilar artery dolichoectasia may rarely cause compression of the optic tract and progressive visual loss.

Diffusion-weighted imaging shows cytotoxic and vasogenic edema in eclampsia.

In eclampsia, MR imaging shows reversible T2 hyperintensities in a parietal and occipital distribution. Findings on diffusion-weighted images suggest that these abnormalities are areas of vasogenic edema. We describe the presence of both cytotoxic and vasogenic edema, as detected by diffusion-weighted imaging, in a woman with eclampsia. Follow-up MR imaging showed that the regions of cytotoxic edema progressed to cerebral infarction. This case suggests that diffusion-weighted imaging allows the early detection of ischemic infarcts in patients with eclampsia.

CT-revealed choroidal effusions as a sign of carotid cavernous fistula.

Choroidal effusions may appear as subtle abnormalities on CT scans. Recognition of choroidal effusions, however, is critical because they may be an early sign of ocular pathologic abnormality. After detection, the various causes of choroidal effusions, such as carotid cavernous fistulas, ocular hypotony, tumors, and inflammatory conditions, should be considered.

Enhancing meningeal blood vessels masquerading as leptomeningeal spread of tumor in obstructive hydrocephalus.

MR showed an enhancing mass in the pineal region and hydrocephalus and leptomeningeal enhancement, thought to indicate pinealoblastoma with leptomeningeal spread. During resection there was no evidence of spread, and repeat MR showed no residual tumor or meningeal enhancement, so the patient was not treated for metastasis. Because there were no signs of leptomeningeal tumor 4 months after surgery, the meningeal enhancement is thought to have been related to venous stasis secondary to obstructive hydrocephalus.

Lack of normal MR enhancement of the pituitary gland: findings in three siblings with combined pituitary hormone deficiency.

We present the MR appearance of the sella turcica in three sibling dwarfs with combined pituitary hormone deficiency in which MR images revealed a peripheral curvilinear band of enhancement about the pituitary gland in all three patients, a normal-size pituitary gland in two siblings, a mildly enlarged pituitary gland in one sibling, and a thin infundibulum and a normal posterior pituitary bright spot in all three siblings. Possible antecedents include an abnormal vascular supply, pituitary gland replacement by a nonfunctioning adenoma, a proteinaceous cyst, or a hamartoma.

111In octreotide scintigraphy in the evaluation of head and neck lesions.

PURPOSE: To evaluate indium 111 octreotide scintigraphy for the detection of suspected neuroendocrine lesions of the head and neck. METHODS: After receiving 6 mCi of 111In octreotide, 22 patients with suspected lesions of the head and neck were examined with both planar and single-photon emission CT (SPECT). Static images, obtained at 4 hours, included the head/neck, chest, abdomen, and pelvis. Additional SPECT images were obtained at 4 or 24 hours. Studies were compared with available conventional radiologic examinations (12 CT, 11 MR, and three angiographic studies) as well as with clinical and pathologic findings. RESULTS: Eighteen of the 22 patients had abnormal findings at scintigraphy. Eleven paragangliomas were seen in 10 patients, metastatic medullary thyroid carcinoma in three patients, thyroid adenoma in two patients, and Merkel cell tumor, carcinoid, and plasmacytoma in one patient each. Surgical confirmation was available in 13 patients. The smallest lesion detected was 1.5 cm. There was one false-positive and one false-negative examination. CONCLUSION: 111In octreotide scintigraphy is a useful imaging tool for the detection of primary and metastatic neuroendocrine tumors of the head and neck that are larger than 1.5 cm. This technique enables distinction of glomus tumors from other masses (such as neuromas) and can be used in the postoperative setting to distinguish scar from recurrent paraganglioma. Since it is an examination of the entire body, it has great utility for detecting multicentric paraganglioma and for screening patients with familial paraganglioma.

Progressive posttraumatic myelomalacic myelopathy: imaging and clinical features.

PURPOSE: To describe the imaging features, surgical management, and clinical outcome of progressive posttraumatic myelomalacic myelopathy (PPMM), a relatively unrecognized but important cause of progressive myelopathy in patients with previous spinal cord injuries. METHODS: The clinical records, imaging studies, and postoperative outcome of 10 patients with PPMM were reviewed. Fifteen preoperative and five postoperative MRs were analyzed for intramedullary signal abnormalities, the nature of these signal abnormalities, and cord tethering. All patients had intraoperative sonography. RESULTS: Neurologic signs and symptoms found in our patients included 1) progressive loss of motor function (6/10), 2) sensory level changes (4/10), 3) increased spasticity (4/10), 4) autonomic dysreflexia (4/10), 5) loss of bowel or bladder control (4/10), and 6) local and/or radicular pain (4/10). Preoperative MR in nine patients revealed intramedullary T1/T2 lengthening (9/9), extramedullary tethering/adhesions (9/9), ill-defined lesional borders (6/9), cord expansion (5/9), and increased signal intensity of the lesion on T1-weighted images compared with CSF (7/9). Proton density images in five patients demonstrated a relative increase in signal intensity over CSF. In all five postoperative MRs, there was evidence of untethering of the spinal cord and a decrease in cord size in two patients. Intraoperative sonography revealed cord tethering and abnormal cord echotexture in all cases. Postoperative clinical evaluation revealed neurologic improvement in nine patients. CONCLUSIONS: PPMM may clinically and radiographically mimic progressive posttraumatic cystic myelopathy (PPCM). MR provides clues to the diagnosis of myelomalacia preoperatively. Intraoperative sonography confirms the absence of a confluent cyst. These points are crucial in the surgical procedures in PPMM vs PPCM. In PPMM, lysis of intradural adhesions results in an improvement in symptoms in a manner similar to the shunting of PPCM.

Creutzfeldt-Jakob disease: focal symmetrical cortical involvement demonstrated by MR imaging.

The authors present two biopsy-proved cases of Creutzfeldt-Jakob disease. MR appears to be more sensitive than CT in detecting pathologic changes; signal abnormalities, when found, are predominantly within gray matter and may involve only peripheral cortex.

Central nervous system tuberculosis in HIV-infected patients: clinical and radiographic findings.

PURPOSE: To characterize the radiographic findings on neuroimaging of 25 human immunodeficiency virus (HIV)-seropositive patients with proved central nervous system tuberculosis and to correlate those findings with clinical data. METHODS: Twenty-five HIV-seropositive patients with central nervous system tuberculosis were identified, and their imaging studies (CT and, in some cases, MR) and medical records were reviewed. The diagnosis of central nervous system tuberculosis was based on cerebrospinal fluid culture (n = 20), biopsy (n = 4), and/or autopsy (n = 5), with a clinical diagnosis of central nervous system tuberculosis in one additional patient. Results also were correlated with CD4 counts and chest x-ray findings. RESULTS: Nine (36%) of 25 patients demonstrated meningeal enhancement. Eleven (44%) of 25 demonstrated enhancing parenchymal lesions; 6 patients had tuberculomata, and 5 had tuberculous abscesses. Communicating hydrocephalus was present in 8 (32%) of 25, and infarction was seen in 9 (36%) of 25. Fifteen of 23 chest x-rays were suggestive of pulmonary tuberculosis. Mean CD4 count was 162. Nine (38%) of 24 patients had a history of pulmonary tuberculosis, and 5 (21%) of 24 had no history of tuberculosis or any other opportunistic infection. Overall mortality was 79%. CONCLUSION: Central nervous system tuberculosis has a very high mortality among HIV-infected patients. Because cerebrospinal fluid cultures can take 6 to 8 weeks, the neuroradiologist can play a critical role in patient treatment by suggesting the correct diagnosis based on characteristic imaging findings. Radiographic clues include multiloculated abscess, cisternal enhancement, basal ganglia infarction, and communicating hydrocephalus, which are not findings associated with the more commonly encountered central nervous system lymphoma or toxoplasma encephalitis. Central nervous system tuberculosis may be the initial presentation of acquired immunodeficiency syndrome. In patients with suspected central nervous system tuberculosis, chest x-ray may provide additional support for the diagnosis of tuberculosis.

MR of omental myelosynangiosis.

PURPOSE: To describe MR findings in patients who have undergone omental transposition (omental myelosynangiosis) for spinal cord revascularization. METHODS: Spin-echo MR images, without and with intravenous gadolinium, were obtained before and after surgery in three patients using a quadrature spine coil. Three-dimensional time-of-flight spinal MR angiography was also performed. RESULTS: On routine MR, the transposed omentum is an irregular, lobulated fat-equivalent mass, containing serpiginous areas of flow void, which extends through the laminectomy site to lie directly adjacent to the cord surface. MR angiography demonstrated small omental vessels, some coursing to the omentum-cord interface; however, no definite extension into the cord was detected. In all patients, there was alteration in cord size and contour after transposition, but no change in cord signal. Clinical improvement was observed in one of the three patients. The signal characteristics of the transposed omentum changed, showing less homogeneity and a gradual loss of the signal over a period of 4 months. CONCLUSIONS: MR delineates transposed omentum and associated postoperative changes in omental myelosynangiosis. MR angiography is useful as an adjunct to demonstrate the small vessels near the omentum-cord interface, but lacks sufficient resolution to demonstrate neoangiogenesis within the cord.

Progressive posttraumatic myelomalacic myelopathy: treatment with untethering and expansive duraplasty.

Patients with progressive posttraumatic myelomalacic myelopathy (PPMM), or tethered cord syndrome, present with symptoms and signs similar to those observed in case of progressive posttraumatic cystic myelopathy, that is, sensorimotor function deterioration, local and/or radicular pain, increased spasticity, increased autonomic dysreflexia, and sphincter dysfunction. The authors investigated surgical outcomes of untethering combined with expansive duraplasty. Forty patients with PPMM who presented with functional deterioration underwent untethering of the spinal cord and nerve roots with an expansive duraplasty. Meticulous dissections of adhesions on the dorsal and lateral aspects of the spinal cord and nerve roots were performed. Intraoperative ultrasonography was used to detect the presence of a confluent cyst and to assess the success of untethering. After surgery, the patients were treated using a protocol that involved frequent turning for 48 hours and subsequently mobilization. Preoperative magnetic resonance (MR) imaging, with and without administration of a contrast agent, was obtained in all patients, except one patient who underwent immediate and delayed computerized tomography (CT) myelography. The mean follow-up period was 3 years (range 20-57 months) for the 36 patients available for follow-up review. Spinal cord tethering was observed in all patients preoperatively. Trauma was the most common cause of this pathology, accounting for 31 of the 40 cases. Preoperative MR imaging did not demonstrate tumor recurrence in the group of five patients who had undergone an initial operation for tumor excision. The interval between the causative event and the operation was less than 5 years in half of the patients (20 of 40), with the longest interval lasting up to 37 years. Motor function deterioration was the most frequent manifestation; it was present in 31 of 40 patients. Improvements in motor function, autonomic dysreflexia, pain, sphincter dysfunction, and sensory function were found during the most recent follow-up examination in 79%, 75%, 62%, 50%, and 43% of the patients, respectively. Two patients experienced retethering of the spinal cord and one underwent a second operation. Surgical untethering and expansive duraplasty, followed by postoperative position rotation to avoid retethering, provide symptomatic relief for patients with PPMM.

Magnetic resonance imaging of unusual intracranial infections.

We review the etiologic agents, epidemiology, pathogenesis, pathology, clinical manifestations, and imaging features of several unusual intracranial infections that have not been discussed elsewhere in this issue. The central nervous system (CNS) infections discussed are Creutzfeldt-Jakob disease (CrJaD), neurosyphilis, primary amebic meningoencephalitis (PAM), granulomatous amebic encephalitis (GAE), cerebral amebiasis, and cerebral hydatid disease.

Walker-Warburg syndrome: neurologic features and muscle membrane structure.

Walker-Warburg syndrome is an autosomal-recessive genetic disorder characterized by congenital muscular dystrophy in association with complex developmental abnormalities of the central nervous system and the eyes. Two patients with Walker-Warburg syndrome are presented to demonstrate clinical variability. Previously unreported pathologic findings involving heart, muscle, spinal cord, and gall bladder are described, and the literature is reviewed. Histopathologic studies of the muscle membrane protein network in both Walker-Warburg syndrome patients reveal a decreased immunostaining for laminin alpha2 and beta-dystroglycan. The clinical, histologic, and biochemical variability in Walker-Warburg patients may reflect heterogeneity.

Adrenocortical carcinoma with cerebral metastasis in a child: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: Adrenocortical carcinoma (ACC) is rare in the pediatric population, and brain metastasis seldom occurs. CLINICAL PRESENTATION: The authors report a case of metastatic ACC to the brain in a 9-year-old patient who had an adrenal cortex neoplasm removed at 4 years of age, and was free of symptoms for 5 years. Two weeks before admission she complained of blurred vision in both eyes. INTERVENTION: Examination revealed bilateral papilledema, and a Magnetic Resonance Imaging (MRI) of the brain revealed a mass in the left lateral ventricle with extensive vasogenic edema and hydrocephalus. The tumor was removed, and histopathologic examination demonstrated metastatic ACC. CONCLUSION: Although ACC is a rare neoplasm it must be considered in the differential diagnosis of cerebral lesions in patients with a history of this tumor. Periodic long-term brain imaging is suggested as part of the follow up in patients with adrenocortical neoplasms.

Encephalitis, cerebritis, and brain abscess: pathophysiology and imaging findings.

This article discusses the imaging findings of encephalitis, cerebritis, and brain abscess in immunocompetent patients. MR imaging is the procedure of choice in evaluating suspected intracranial infections because of its inherent contrast resolution, multiplanar capability, improved sensitivity in the posterior fossa, sensitivity to the presence of subacute, and chronic hemorrhage, and its sensitivity to the detection of meningeal disease on postcontrast images. Discussion of pathologic conditions and imaging features of encephalitis are based on the most common causative agents of each type of disease. Imaging features and pathologic conditions of cerebritis and brain abscesses also are reviewed with emphasis on pyogenic bacteria.

The role of CT following aneurysmal rupture.

Computed tomography is a highly effective method of detecting subarachnoid blood if performed early after aneurysmal rupture, being 95% to 98% positive when lumbar puncture is positive. The localization of the blood defines the location of the aneurysm in approximately 80% of cases. Contrast enhanced computed tomography demonstrates the aneurysm in 75% of cases with the aneurysm is greater than 5 millimeters in size. Computed tomography angiography defines the aneurysm in up to 96% of cases. The amount of subarachnoid blood correlates with the development of vasospasm; cerebral perfusion can be further evaluated with xenon-enhanced computed tomography.

Emotional activation of obese and normal women due to imagery and food content of verbal stimuli in a memory task.

The aim of this study is to look for correlation between a physiological variable (skin conductance, SCL) and cognitive variables (reaction time, RT and productivity score) obtained in a memory task. Subjects were 17 females, including 7 patients and 10 controls. Patients were recruited among women who went to a clinic for alimentary disorders because of obesity and volunteered for this study; controls were normal women of comparable age without any alimentary problem. Tonic variations of SCL were recorded by a computerized polygraph during the execution of the cognitive task, which consisted of a computerized presentation of frequent, everyday used words evenly divided according to an alimentary/nonalimentary content and to a high/low imagery quality. The acquisition session was followed by an immediate recognition session where subjects were asked to identify the previously presented words among an equal number of similar words not included in the acquisition list. The two session series (acquisition and recognition) were repeated three times to evaluate the learning curve and habituation. This same procedure was separately performed with high imagery alimentary/nonalimentary words and with another list of low imagery alimentary/nonalimentary words. During the recognition tasks, both RT and productivity scores were recorded. A correlation analysis between cognitive and physiological variables was carried out to explore how subjects with different attitudes to food react in cognitive and somatic terms when exposed to verbal stimuli concerning this topic and to neutral verbal stimuli. Results show that obese patients have a different emotional activation in front of these verbal stimuli where both the cognitive activity and the somatic responses are affected by their involvement with the verbal stimuli. On the contrary, the imagery effect does not seem to be influenced by the content and by the idiosyncratic reactions to it of the specific groups of subjects.

Discharge planning and diagnosis-related groups in military hospitals: key issues and essential elements.

As pressures for cost containment in health care continue to mount, military hospitals will inevitably be affected. Cost-containment strategies used in civilian hospitals such as diagnosis-related groups will continue to be implemented in military health care facilities. Effective discharge planning is essential for dealing successfully with pressures for cost containment. Key elements in an effective discharge planning program are discussed.

Term angular pregnancy with placenta accreta. A case report.

A 27-year-old primigravida, with two prior adnexal operations, had retained placenta with postpartum haemorrhage following an uncomplicated vaginal delivery. Laparotomic removal revealed placental accretism. Pharmacological treatment (oxytocin and sulprostone) and right cornual resection failed to control profuse bleeding. In the end, subtotal hysterectomy was unavoidable.