Comparison of conventional external radiotherapy and stereotactic radiotherapy in the treatment of pituitary adenoma.

OBJECTIVE: To compare the results of pituitary adenoma treated with conventional external beam radiotherapy (EBRT) versus stereotactic radiosurgery and stereotactic radiotherapy (SRS/SRT). METHOD AND MATERIAL: Data of patients with pituitary adenoma treated at Radiotherapy and Oncology unit, Ramathibodi Hospital between 1990 from 2003 were retrospectively collected and analyzed. Twenty-two patients were treated with EBRT and 51 patients were treated with SRS/SRT. RESULTS: The 5-year overall survival and local control rates were not different between the EBRT and SRS/SRT group (91% vs 100%, p = 0.10; 95% vs 96%, p = 0.33). The 5-year freedom from newly initiated hormonal replacement was 50% in EBRT and 75% in SRS/SRT group (p = 0.38). CONCLUSION: At a similar outcome but with lower expense of resources, EBRT should be considered an acceptable radiation technique for patients with pituitary adenoma, especially in developing countries such as Thailand.

Computer tomographic findings of the brain in HIV-patients at Ramathibodi Hospital.

OBJECTIVE: To determine the underlying cause of the brain lesions in adult HIV patients referred for CT scan at Ramathibodi Hospital and to evaluate accuracy of CT for the diagnosis of the brain lesion. MATERIAL AND METHOD: Data from first CT scan of the brain of 195 adult HIV patients at Ramathibodi Hospital were reviewed The final diagnoses from medical records were assessed followed by CSF analysis, pathological report, and therapeutic treatment. The accuracy of the CT brain was evaluated using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: One hundred ninety five adult seropositive patients for HIV underwent CT scan of the brain, 59% were HIV encephalopathy (HIVE), 22% toxoplasmosis, 9% cryptococcoma, 5% tuberculous meningitis, 4% tuberculoma, 3% progressive multifocal leukoencephalopathy (PML), 2% lymphoma, and 1% normal. In non-specified causes (from CT scan), 33% were meningitis, 4% cerebritis, and 5% infarction. CT was found to have high sensitivity, specificity, PPV, and NPV for toxoplasmosis (92%, 96%, 86%, and 98%, respectively). CONCLUSION: HIV encephalopathy was the most common finding of adult HIV brains. Toxoplasmosis was the most common opportunistic parenchymal brain lesion in adult HIV brains. CT was the modality of choice for diagnosis and exclusion of toxoplasmosis, but it cannot determine the cause of disease showing meningitis pattern.

Parapharyngeal [corrected] salivary duct carcinoma involving the cavernous sinus.

Salivary duct carcinoma (SDC) is a relatively uncommon malignant tumor of the salivary gland derived from the excretory duct reserve cells of the salivary glands. The authors report a case of SDC in a 34-year-old man who presented with trismus and left sided headache, radiologically by a left parapharyngeal mass involving into the left cavernous sinus and histologically by intraductal growth pattern with a cribriform appearance and comedonecrosis. Perineural invasion of the mandibular branch of trigeminal nerve is demonstrated. Clinical and pathologic features with relevant literatures are reviewed.

Magnetic resonance venography in intracranial veno-occlusive disease.

OBJECTIVE: To identify the common MR Vfindings in the patient diagnosed intracranial veno-occlusive disease at Ramathibodi Hospital and to identify the underlying conditions that probably predisposed the patient to the intracranial veno-occlusive disease. MATERIAL AND METHOD: Sixty-four patients with clinically suggestive intracranial veno-occlusive disease who underwent MRV were reviewed in terms of signs and symptoms, MRV methods, MRV findings, and clinical diagnosis after report MRV In cases diagnosed to have intracranial veno-occlusive disease, the patients' records were reviewed to identify predisposing conditions. RESULTS: Thirty-four patients were diagnosed to have intracranial veno-occlusive disease. The common findings were lack of typical high flow signal from a sinus that did not appear aplastic or hypoplastic, frayed appearance of flow signal from a sinus at a later stage of the thrombus, and collateral vessels and cerebral hemorrhage. The common sites were superior sagittal sinus, and left and right transverse sinuses. Hypoplasia, a normal variation, was incidentally found in eight patients (12.5%). The most common hypoplastic site was the left transverse sinus. Contributing factors in patients diagnosed to have intracranial veno-occlusive disease in the present series were birth control pill in take, tumor (meningioma, and malignant schwannoma of the scalp), blood dyscrasia, AVM, hypotension, and abscess. The causes of intracranial venous thrombosis could not be identified in seven patients (21%). CONCLUSION: The common MR Vfinding in acute intracranial veno-occlusive disease was lack of typical high flow signal from a sinus while frayed appearance of flow signal from a sinus was the common direct sign in chronic condition. In the present series, birth control pill intake was the most common contributing factor

Development of two oral contrast materials for CT evaluation of the esophagus.

BACKGROUND: Computed tomography (CT) is a widely available modality in evaluating benign and malignant diseases of the esophagus. To date, there is no substantial consensus on the optimal and widely available method for opacifying the esophageal lumen exists for CT OBJECTIVE: The present study was performedf or complete and continuous opacification of the esophagus using two developed oral contrast materials and a commercial barium paste formulated for CT MATERIAL AND METHOD: One hundred and seven adult patients were sent for spiral routine CT scan of the chest (Light speed plus; General Electric Medical System, Milwaukee, Wis., USA) to evaluate variety of clinical conditions at Ramathibodi Hospital. They were divided into three groups. Two developed oral contrast materials, 1.5%(wt/vol) carboxy-methyl cellulose sodium paste containing 2%(wt/vol) barium sulfate and 5.5%(wt/vol) potato starch containing 2%(wt/vol) barium sulfate, and a commercial barium paste were randomly administered Data collection and analysis of the CT findings were performed double blindly. Results: The patients undergoing CT scan of the chest were performed with one of the oral contrast material. No streak artifact was present in any of the CT slices. Of the grade 1, contrast present without luminal distension and grade 2, contrast present with luminal distension, 1.5% CMC containing 2% barium sulfate was opacified in 36.48% and 17.45/o, respectively. Opacification with 5.5% starch containing 2% barium sulfate was of 36.41% and 19.71% while that of 3% commercial barium paste was of 36.68% and 27.54%, respectively. Acceptable taste was also achieved However, mild to moderate difficulty in swallowing occurred in 35% with no medication or intervention needed CONCLUSION: All oral contrast materials tested were less continuous and did not opacified the esophageal lumen as much when compared with the prior studies. However, acceptable taste, only mild to moderate difficulty in swallowing during the procedure, and significantly cheaper cost enable them to be used in selected cases in CT scan of the neck, chest, and upper abdomen for clarification of the problem areas.

Magnetic resonance imaging of the brain in epileptic adult patients: experience in Ramathibodi Hospital.

OBJECTIVE: The purpose of the present study was to classify the imaging structural abnormalities of epileptic adult patients referred for magnetic resonance imaging (MR imaging) of the brain at Ramathibodi Hospital and to correlate with the clinical data and EEG. MATERIAL AND METHOD: MR imaging of 91 adult epileptic patients (age ranging from 15-85 years old with an average of 36.90 years old) were retrospectively reviewed and classified into eight groups according to etiologies. Then clinical data and EEG correlations were analyzed using the Kappa analysis. All of the MR imaging of the brain were performed at Ramathibodi Hospital from January 2001 to December 2002. RESULTS: Secondary generalized tonic clonic seizure was the most common clinical presenting seizure type. Extra temporal lobe epilepsy was the most common clinical diagnosis. Of the thirty-three patients who underwent EEG before performing MR imaging, 17 had normal EEG From MR imaging, temporal lobe lesion was the main affected location and mesial temporal sclerosis (MTS) was the most common cause of the epilepsy in patients. For age group classification, young adult (15-34 years old) and adult (35-64 years old) age groups, MTS was the most common etiology of epilepsy with cortical dysplasia being the second most common cause for the first group and vascular disease for the latter group. For the older age group (> 64 years old), vascular disease and idiopathic cause were equally common etiologies. MRI, EEG findings, and clinical data were all concordant with statistical significance. CONCLUSION: MRI is the non-invasive modality of choice for evaluation of the epileptic patients. The result is concordant with the clinical and EEG findings. It can detect and localize the structural abnormality accurately and is useful in the treatment planning.

Comprehensive assessment of a post-coronary bypass graft patient with cardiovascular magnetic resonance imaging and multi-detector computed tomography / 老年心脏病学杂志（英文版）

Coronary bypass graft surgery (CABG) is a revascularization procedure which reduces myocardial ischemia and cardiovascular morbidity and mortality in selected patients; however, up to 40% of saphanous vein grafts may degenerate over 10 years. Although coronary angiography is the gold standard to detect graft patency and native vessel disease, sometimes it is difficult to locate the grafts resulting in increased exposure to radiation and contrast administration. This case highlights the utility of cardiac computerized tomography and magnetic resonance imaging to provide comprehensive noninvasive assessment in a patient post CABG.

Cardiovascular examination with 3.0 Tesla magnetic resonance imaging: first 100 cases at Ramathibodi Hospital.

BACKGROUND: Cardiovascular magnetic resonance imaging (CMR) has been utilized for diagnosis in various cardiovascular diseases and most of those were performed on a 1.5 Tesla CMR system. Recently, a 3.0 Tesla magnetic resonance imaging system has been introduced into clinical practice, however the clinical experience on cardiovascular examination using this system is limited. Therefore, the authors' institution has integrated a team for developing a CMR program on this 3.0 Tesla system. OBJECTIVE: To describe the authors' experience on the 3.0 Tesla CMR system. MATERIAL AND METHOD: The data on patients referred to the authors' CMR unit between August 2004 and October 2005 were reviewed. RESULTS: One hundred patients were referred for CMR examination. The mean age was 56 years (2 month - 85 years) and 65 patients were male. The most common indication was to assess coronary artery disease (64 patients). The performed examination was divided into cardiac structure and function assessment (39%), stress testing (23%), coronary magnetic resonance angiography (13%), myocardial viability assessment (12%), magnetic resonance angiography (9%), and flow assessment (4%). CONCLUSION: The present study highlights that comprehensive assessment of various cardiovascular diseases can be performed on the 3.0 Tesla CMR system.

MRI findings of the cavernous sinus metastasis with inferior extension mimicking a nasopharyngeal carcinoma with cavernous sinus invasion.

The authors report the MRI findings in a patient with cavernous sinus metastasis with inferior extension to the nasopharynx, mimicking imaging findings of the advanced nasopharyngeal cancer with the skull base, and intracranial extension. Findings of denervative atrophy of the masticator muscles and obstruction of the Eustachian tube resulting in fluid retention of mastoid air cells are seen in both processes.

Accuracy of sixteen-slice CT scanners in detected coronary artery disease.

BACKGROUND: The coronary artery disease, now, the incidence is increasing in both developed and developing countries. The investigation is evoluted and non-invasive multislice CT scanners have been used more frequently, although the gold standard is still the coronary angiography. OBJECTIVE: To investigate the accuracy in detected coronary artery disease by using 16-slice CT scanners compared to the conventional coronary angiography. MATERIAL AND METHOD: Fifty-five patients were 43 males, 12 females, median aged 62 years (43-82 years), and average heart rates 67 beats/minute (46-147 beats/minute) had the ECG-gated CT angiography followed by coronary angiography in 3 months. The ECG-gated CT angiography was performed by using 16-slice MSCT detector (0.42-s rotation time, 16 x 0. 75-mm detector collimation). RESULTS: All patients were classified into two major groups; one was significant coronary artery stenosis which was designed by stenosis at least 50% and the other was non-significant stenosis which was designed by normal or stenosis less than 50%. The site having blooming artifact due to calcification that causes complete obliteration of the lumen or having significant motional artifacts was ruled out. There were 285 evaluable sites in 19 patients with high heart rates, more than 70 beats/minute. The sensitivity, specificity, and accuracy in significant stenosis were 72.9%, 99.6%, and 94.0% respectively. In 36 patients with a lower heart rate, there were 563 evaluable sites, the sensitivity was 86.5%, specificity was 98.5%, and accuracy was 96.6%. The overall showed 81.1% of sensitivity, 98.9% of specificity, and 95.8% of accuracy. CONCLUSION: The accuracy of the 16-slice CT angiography for patients suspected of having coronary artery disease was high. However, blooming artifacts from the calcium, respiratory artifacts, and small size of the distal and branching artery still caused limited luminal assessment. These problems have challenged the new coming generation of MDCT.

Magnetic resonance imaging of the brain in epileptic pediatric patients: review of the experience in Ramathibodi Hospital.

OBJECTIVE: To review a series of epileptic children referred for MR imaging and correlate the structural abnormalities from the MRI findings with clinical data and EEG. MATERIAL AND METHOD: Retrospective review of MRI of the brain performed in children, aged less than 15 years with epilepsy at Ramathibodi Hospital from January 1999 to December 2002 was done. There were 100 children (57 girls, 43 boys) with epilepsy, age range from one month to 14 years, mean 7 years and 5 months. Diagnosis of seizure type and epilepsy were classified according to clinical presentation and EEG. RESULTS: There were 16 children with primary generalized seizure, 79 children with partial or complex partial seizures with or without secondary generalization. The remaining 5 children had a specific syndrome. The most common etiology of all patients was congenital disease, especially cortical dysplasia. Among children with partial with or without generalization, cortical dysplasia was the most common finding (31%). Mesial temporal sclerosis and combined cortical dysplasia with mesial temporal sclerosis were found in 24% and 13.9%, respectively. Most of the disease categories showed significant concordance of the EEG to the MRI findings, except infectious disease. CONCLUSION: The most common etiology of epilepsy in children under 15 years old was cortical dysplasia. For children with partial or complex partial seizure, cortical dysplasia was the most common etiology followed by mesial temporal sclerosis and combined cortical dysplasia with mesial temporal sclerosis, respectively. MRI provides precise etiologic classifications of epilepsy.

Fractionated stereotactic radiotherapy for bilateral vestibular schwannomas associated with neurofibromatosis type 2: early experiences in Ramathibodi Hospital.

PURPOSE: To evaluate the rates of tumor control and useful hearing preservation in patients with bilateral vestibular schwannomas (VSs) associated with neurofibromatosis type 2 (NF-2) treated with fractionated stereotactic radiotherapy (FSRT). MATERIAL AND METHOD: From August 1998--December 2002 there were 5 patients with NF-2 who underwent FSRT (Linac-based system) for bilateral CP angle tumors. Median age was 28 (18-47) years. Median tumor volume was 5.4 (2.2-9.4) cc. Eight lesions received a marginal dose of 44.2-59.9 (median = 46.2) Gy in 25-33 fractions. The other 2 lesions received 4.4 and 4.9 Gy/fraction for 6 fractions in 3 and 2 weeks. Median follow-up was 19 (14-44) months. RESULTS : Radiographic and clinical tumor control rate was 90%. One lesion progressed at 7 months after FSRT and was completely resected Of the 5 lesions with Gardner-Robertson class I-II hearing before FSRT 2 (40%) retained useful hearing at the last follow-up. One patient had left facial spasm at 10 months after FSRT which gradually improved. No patient had facial palsy, facial numbness or pain. CONCLUSIONS : FSRT provided good tumor control and hearing preservation rate in NF-2 patients with minimal morbidity. However, a longer follow-up is needed to evaluate long term results.

Choroidal osteoma in Oriental patients.

BACKGROUND: Choroidal osteoma is a rare tumour of the choroid. This is the first report of cases of choroidal osteoma in Thai patients. OBJECTIVE: To report the clinical characteristics, imaging findings and long-term follow-up of choroidal osteoma in four Oriental patients. METHOD: Four cases of choroidal osteoma were observed for 5 years or more. RESULTS: All patients were young female patients whose ages ranged from 24 to 37 years. Three were unilateral and one was bilateral. The tumors were located at the juxtapapillary and macular area with overlying serous retinal detachment. Two patients had previous thyroid diseases and one was pregnant when the tumors were diagnosed. Osteoma did not develop in the vicinity of posterior staphyloma of high myopic eyes. Echography showed acoustic features of a plano-convex sonically dense lesion with high reflectivity echoes which persisted despite lower system sensitivity. None had subretinal neovascularization. Subretinal fluid disappeared spontaneously within one to 14 months in three patients. Gradual growth of the tumor in a pseudopodium manner developed from two to six years after initial examination. Decalcification occurred spontaneously or after laser ablation. CONCLUSIONS: The authors presented four Oriental patients with choroidal osteoma who were observed for at least 5 years. Echography is the best method for identifying this lesion and has unique acoustic features. Subretinal fluid can be seen in the absence of subretinal neovascularization and resorbs spontaneously. Decalcification occurred as a natural process or after laser ablative treatment. Hormonal changes may implicate the development of this tumor.

Localization of sensorimotor cortex by using functional magnetic resonance imaging: comparison between finger tapping and palm scratching in normal volunteer.

The purpose of this study was to compare the location and intensity of activation of the sensorimotor cortex between finger tapping and palm scratching paradigms in normal volunteers and to consider using passive task instead of motor task in patients who are unable to perform motor task. Multishot echo-planar T2*-weighted imaging sequences at the level of the sensorimotor cortex were performed in axial plane during finger tapping and palm scratching paradigms in 13 normal volunteers. The authors found that the location of activation was slightly posterior only in bilateral passive task compared to bilateral motor task but there was no statistical significance. However, this observation was not seen in unilateral tasks. The intensity of activation of both motor and passive tasks was comparable. The authors conclude that in normal volunteers passive task (palm scratching) can be used instead of motor task (finger tapping) to localize the location of the sensorimotor cortex.

Detection of JC virus infection in progressive multifocal leukoencephalopathy: the first documented case in Thailand.

Progressive Multifocal Leukoencephalopathy (PML) is a demyelinating brain disease caused by human polyoma JC virus (JCV). This disease is an important cause of morbidity and mortality in AIDS patients. Definite diagnosis currently requires a brain biopsy. PCR for JCV of CSF, an emerging diagnostic tool, has a high specificity for the diagnosis of PML in patients with characteristics on clinical and neuroradiological findings. The authors report a 36-year-old woman who presented with prolonged fever, progressive weakness, and slow speech for 2 months. Clinical features and MRI findings were compatible with PML. Qualitative PCR for JCV of CSF showed a positive result. This report emphasizes the yield of PCR, the CSF for JCV in a diagnosis of PML, which may reduce the need for a brain biopsy in such cases.