Comparison of MRI Sequences for the Detection of Cerebral Venous Sinus Thrombosis During Follow-Up Examination

PURPOSE@#To compare the diagnostic performance of magnetic resonance (MR) sequences for the evaluation of cerebral venous sinus thrombosis (CVST) during follow-up examinations.@*MATERIALS AND METHODS@#Thirteen cases that were confirmed to be CVST between January 2006 and March 2016 were included in this study. Two neuroradiologists independently examined each initial and follow-up MR sequence image in random order.@*RESULTS@#Gadolinium-enhanced T1-weighted imaging (Gd-enhanced T1WI) was the most sensitive sequence for the detection of CVST in the initial and follow-up MR examinations (82% and 55.3%, respectively). Among the non-enhanced MR sequences of the initial examination, gradient-recalled echo was the most sensitive (77.4%), fluid-attenuated inversion recovery (FLAIR) had low sensitivity (34.4%). The overall diagnostic performances of all MR sequences except for FLAIR decreased during the follow-up. FLAIR was the most sensitive during follow-up, and was also the only sequence with increased sensitivity during follow-up (from 34.4% to 55.6%).@*CONCLUSION@#Gd-enhanced T1WI had the best diagnostic performance for CVST in both initial and follow-up MR examinations. Therefore, it is reasonable to use Gd-enhanced T1WI to evaluate CVST during follow-up examinations. However, for patients who cannot tolerate MR contrast agents, the use of FLAIR to assess the remaining CVST during the follow-up may be helpful.

Feasibility and Safety of Mild Therapeutic Hypothermia in Poor-Grade Subarachnoid Hemorrhage: Prospective Pilot Study

Therapeutic hypothermia (TH) improves the neurological outcome in patients after cardiac arrest and neonatal hypoxic brain injury. We studied the safety and feasibility of mild TH in patients with poor-grade subarachnoid hemorrhage (SAH) after successful treatment. Patients were allocated randomly to either the TH group (34.5°C) or control group after successful clipping or coil embolization. Eleven patients received TH for 48 hours followed by 48 hours of slow rewarming. Vasospasm, delayed cerebral ischemia (DCI), functional outcome, mortality, and safety profiles were compared between groups. We enrolled 22 patients with poor-grade SAH (Hunt & Hess Scale 4, 5 and modified Fisher Scale 3, 4). In the TH group, 10 of 11 (90.9%) patients had a core body temperature of 95% of the 48-hour treatment period. Fewer patients in the TH than control group (n = 11, each) had symptomatic vasospasms (18.1% vs. 36.4%, respectively) and DCI (36.3% vs. 45.6%, respectively), but these differences were not statistically significant. At 3 months, 54.5% of the TH group had a good-to-moderate functional outcome (0–3 on the modified Rankin Scale [mRS]) compared with 9.0% in the control group (P = 0.089). Mortality at 1 month was 36.3% in the control group compared with 0.0% in the TH group (P = 0.090). Mild TH is feasible and can be safely used in patients with poor-grade SAH. Additionally, it may reduce the risk of vasospasm and DCI, improving the functional outcomes and reducing mortality. A larger randomized controlled trial is warranted.

Asymptomatic moyamoya syndrome, atlantoaxial subluxation and basal ganglia calcification in a child with Down syndrome / 소아과

Down syndrome, the most common chromosomal abnormality, may be associated with various neurologic complications such as moyamoya syndrome, cervical spinal cord compression due to atlantoaxial subluxation, and basal ganglia damage, as well as epileptic seizures and stroke. Many cases of Down syndrome accompanied by isolated neurologic manifestations have been reported in children; however, Down syndrome with multiple neurologic conditions is rare. Here, we have reported a case of Down syndrome in a 10-year-old girl who presented with asymptomatic moyamoya syndrome, atlantoaxial subluxation with spinal cord compression, and basal ganglia calcification. To the best of our knowledge, this is the first report of Down syndrome, in a child, which was accompanied by these 3 neurologic complications simultaneously. As seen in this case, patients with Down syndrome may have neurologic conditions without any obvious neurologic symptoms; hence, patients with Down syndrome should be carefully examined for the presence of neurologic conditions.

A Case of Atypical Skull Base Osteomyelitis with Septic Pulmonary Embolism

Skull base osteomyelitis (SBO) is difficult to diagnose when a patient presents with multiple cranial nerve palsies but no obvious infectious focus. There is no report about SBO with septic pulmonary embolism. A 51-yr-old man presented to our hospital with headache, hoarseness, dysphagia, frequent choking, fever, cough, and sputum production. He was diagnosed of having masked mastoiditis complicated by SBO with multiple cranial nerve palsies, sigmoid sinus thrombosis, and septic pulmonary embolism. We successfully treated him with antibiotics and anticoagulants alone, with no surgical intervention. His neurologic deficits were completely recovered. Decrease of pulmonary nodules and thrombus in the sinus was evident on the follow-up imaging one month later. In selected cases of intracranial complications of SBO and septic pulmonary embolism, secondary to mastoiditis with early response to antibiotic therapy, conservative treatment may be considered and surgical intervention may be withheld.

A Case of Cerebellar Dysfunction After Acute Organotin Poisoning / 대한산업의학회지

BACKGROUND: We performed a follow-up study of an acute organotin poisoning case on the neurological sequelae that remained after 3 years since diagnosis. CASE: In the previous study, a 43-year-old male was reported for acute organotin poisoning. After 3 years, the neurological sequelae were studied using neurological examination, cognitive tests, neurobehavioral tests (by CAYSYS 2000(TM)), brain magnetic resonance imaging (MRI), and 18F-fluorodeoxyglucose (18F-FDG) PET/CT. Upon neurological examination and other tests, orientation was improved compared to that 3 years before, but cerebellar ataxia, dysmetria and dysdiadochokinesia remained the same, with little change. Brain MRI showed cerebellar atrophy. 18F-FDG PET/CT revealed mildly decreased metabolic activity in the pons and in both cerebellar hemispheres. DISCUSSION: This is the first brain MRI study on cerebellar atrophy caused by organotin poisoning. Cerebellar ataxia was confirmed by decreased metabolic activity in 18F-FDG PET/CT.

A case of scrub typhus with reversible hearing loss / 대한내과학회지

Scrub typhus, which is caused by Orientia tsutsugamushi, is an acute febrile illness characterized by fever, rash, and myalgia. Recently, its incidence in Korea has increased. Many cases of scrub typhus with central nervous system involvement have been reported, while cases with hearing loss are rare. We experienced a case of scrub typhus with reversible hearing loss. To our knowledge, this is the first case confirmed by magnetic resonance imaging.

A case of scrub typhus with reversible hearing loss / 대한내과학회지

Scrub typhus, which is caused by Orientia tsutsugamushi, is an acute febrile illness characterized by fever, rash, and myalgia. Recently, its incidence in Korea has increased. Many cases of scrub typhus with central nervous system involvement have been reported, while cases with hearing loss are rare. We experienced a case of scrub typhus with reversible hearing loss. To our knowledge, this is the first case confirmed by magnetic resonance imaging.

Angiographic Analysis of Cerebral Aneurysm

PURPOSE: To analyze the angiographic findings of cerebral aneurysms and to compare them with previousdomestic and foreign reports. MATERIAL AND METHODS: Three hundred and seventeen patients underwent DSA(digitalsubtraction angiography) and the results were retrospectively, reviewed. Among 278 patients, 356 cerebralaneurysms were detected. Patient's age and sex ratio were analysed, as well as the location, size and multiplicityof the aneurysms. RESULT: The most prevalent age group was 40 to 60 years (n=211, 76%), and the male to femaleratio was 1:1.5. Aneurysms were located in the anterior (n=324, 91%) or posterior circulation(n=32, 9%). In theformer, the most common locations were the anterior communicating artery (n=98, 28%), middle cerebral artery (MCA)bifurcation(n=65, 18%) and the posterior communicating artery (n=32, 9%), while in the pasterior circulation, themost common location was the basilar tip(n=11, 3%). One hundred and eighty-eight cerebral aneurysms(53%) were 3-6mm in size, and 75(21%) were 6-10mm. The size of nine aneurysms (3%) was more than 25mm. Multiple aneurysms(n=149)occurred in 65 patients(23%) ; the most common age group was 40 to 60 (74%) and the male to female ratio was 1:4.The most common number of multiple aneurysms were two (77%) and the common locations were the posteriorcommunicating artery (21%), MCA bifurcation (18%) and anterior communicating artery (13%). CONCLUSION: Weanalyzed a large series in a single center and therefore expect that our data will be helpful for the analysis ofaneurysms in the cerebral circulation and for comparison with domestic and foreign studies.

Usefulness of CT in Patients with Gastrointestinal Fistula

PURPOSE: To evaluate the usefulness of CT in patients with gastrointestinal fistula. MATERIALS AND METHODS: We retrospectively reviewed the CT scans of 17 patients with various type of gastrointestinal fistula. The presence of these fistulae was confirmed by laparotomy in seven patients and by barium studies in fifteen. We evaluated the diagnostic accuracy of CT in these cases, and in correlation with barium studies and surgical findings, subsequently analyzed the CT findings. We determined the presence or absence of fistula tract, flow diversion of oral contrast media, bowel wall changes adjacent to the fistula tract, and extraluminal manifestations such as soft tissue mass, free air, leakage of oral contrast media, and peritoneal changes. RESULTS: The diagnosis of gastrointestinal fistula was possible on CT in nine (53%) of the 17 patients by using the CT criteria of direct visualization of the fistula tract (n=6) or flow diversion of oral contrast media (n=4). Other ancillary findings included bowel wall thickening adjacent to fistula tract in 15 patients, extraluminal soft-tissue mass in five, extraluminal free air in ten, extraluminal contrast leakage in four, and varying degrees of mesenteric and/or omental infiltration in 15. CONCLUSION: CT scanning is useful for the diagnosis of gastrointestinal fistula, which may be possible if the fistula tract and flow diversion of oral contrast materials are seen. It is also useful for evaluation of the extent of the etiologic disease.

MRI Findings of Rathke Cleft Cyst

PURPOSE: To describe the characteristic MRI findings of the Rathke cleft cyst. MATERIALS AND METHODS: During a seven-year period, we retrospectively evaluated the MRI findings of 24 pathologically-proven Rathke cleft cysts. The patients included ten men and 14 women, And their mean age was 37. MRI findings were analyzed in terms of location, shape, size, signal intensity, homogeneity of cyst content, pattern of contrast enhancement, displacement of the pituitary stalk, and mass effect of the cyst on adjacent structures. RESULTS: The location of 14 cases (58%) was sellar or suprasellar; nine (37%) were intrasellar. The mean size of the cysts was 16 x 12mm, as seen on sagittal or coronal images. The characteristic shape of the cyst was a sagging water bag in 13 cases (54%) and upward tenting in eleven (46%). The signal intensity of the cyst varied ; on T1-and T2WI, eleven cases (46%) showed high signal intensity relative to brain parenchyma ; five (21%) showed iso signal intensity on T1WI and high signal intensity on T2WI. While 18 (75%) showed inhomogeneous signal intensity on T1- and T2WI;13 (54%) showed a smudge pattern within the cysts, and six (25%) showed homogeneous signal intensity on T1 and T2WI. On Gd-DTPA enhanced images, thin-rim enhancement surrounding the cyst was seen in 20 cases (83%). While no enhancement was seen within the cyst. Seventeen cases (71%) showed anterior displacement of the pituitary stalk; two showed posterior displacement and five were indeterminate. Mass effect included compression of the optic chiasm (11cases) and bony erosion or tilting of the sellar floor (8 cases). CONCLUSION: MRI findings of midline intrasellar cyst with a sagging water bag appearance, high signal intensity on T1- and T2WI, inhomogeneity of cyst content, and peripheral rim enhancement surrounding the cyst are common, and are characteristic of the Rathke cleft cyst.

Multiple Bony Lesions other than Femoral Heads on

PURPOSE: To evaluate the clinical significance of the multiple increased uptake lesions other than in femoral heads as seen on whole body bone scan in patients with avascular necrosis of femoral heads. MATERIALS AND METHODS: One hundred and seventy three patients with clinical diagnosis of avascular necrosis of fthe emoral head underwent a bone scan using Tc-99m MDP. Increased uptake lesions other than in femoral heads were evaluated, including frequency and common sites of involvement, and correlated with clinical information and plain radiographic findings. Two hundred patients without AVN, who had undergone a bone scan, were included as a control group. RESULTS: Increased uptake lesions in extrafemoral head locations were found in 36 of 173 patients(20.8% ; the location of 79 lesions was other than the femoral head, This result is statistically different from patients without avascular necrosis of femoral head(p<0.0001). The most common site of involvement was the knee joint area(62.5%). Other lesions were located in the mid-shafts of the long bones of the lower extremities, calcaneus, proximal humerus, etc., in order of decreasing frequency. Plain radiographs of 17 lesions were nonspecific, except for three lesions showing definite changes associated with avascular necrosis. The risk factors included alcoholism, the prolonged use of steroids, renal transplantation, herbal medication and working as a working as deep-sea diver. Most patients did not complain of pain, except for two with irreversible osteonecrotic changes as seen on plain radiograph. CONCLUSION: in patients with avascular necrosis of the femur, increased uptake lesions other than in the femoral head as seen on bone scan, may represent the early stage of osteonecrosis, which shows a characteristic appearance on bone scan. In order to avoid possible misdiagnoses of multiple extrafemoral lesions as bony metastasis or traumatic lesions, in patients with avascular necrosis of the femur these should be carefully evaluated.

Multiple Bony Lesions other than Femoral Heads on

PURPOSE: To evaluate the clinical significance of the multiple increased uptake lesions other than in femoral heads as seen on whole body bone scan in patients with avascular necrosis of femoral heads. MATERIALS AND METHODS: One hundred and seventy three patients with clinical diagnosis of avascular necrosis of fthe emoral head underwent a bone scan using Tc-99m MDP. Increased uptake lesions other than in femoral heads were evaluated, including frequency and common sites of involvement, and correlated with clinical information and plain radiographic findings. Two hundred patients without AVN, who had undergone a bone scan, were included as a control group. RESULTS: Increased uptake lesions in extrafemoral head locations were found in 36 of 173 patients(20.8% ; the location of 79 lesions was other than the femoral head, This result is statistically different from patients without avascular necrosis of femoral head(p<0.0001). The most common site of involvement was the knee joint area(62.5%). Other lesions were located in the mid-shafts of the long bones of the lower extremities, calcaneus, proximal humerus, etc., in order of decreasing frequency. Plain radiographs of 17 lesions were nonspecific, except for three lesions showing definite changes associated with avascular necrosis. The risk factors included alcoholism, the prolonged use of steroids, renal transplantation, herbal medication and working as a working as deep-sea diver. Most patients did not complain of pain, except for two with irreversible osteonecrotic changes as seen on plain radiograph. CONCLUSION: in patients with avascular necrosis of the femur, increased uptake lesions other than in the femoral head as seen on bone scan, may represent the early stage of osteonecrosis, which shows a characteristic appearance on bone scan. In order to avoid possible misdiagnoses of multiple extrafemoral lesions as bony metastasis or traumatic lesions, in patients with avascular necrosis of the femur these should be carefully evaluated.

Production of Carotid Artery Aneurysm in Pigs

PURPOSE: To establish the method of constructing an experimental aneurysm model in porcine carotid artery. MATERIALS AND METHODS: Fourteen aneurysms were created in the carotid arteries of eight pigs. After paramedian incision under intravenous anesthesia, the common carotid artery and external jugular vein were separated. A portion of the latter was cut to make an aneurysmal sac and this was sutured to the side wall of the common carotid arterial wall (end to side). Within one week, an arteriogram was obtained in all pigs and color Doppler study was performed in four. Digital subtraction arteriograms were serially obtained three images/sec, and these were analyzed to determine the size of the sac and the neck, flow pattern in the aneurysm, and stenosis in the common carotid artery. RESULTS: Arteriographic findings were obtained in ten of 14 aneurysms. Six aneurysms were saccular in shape, and the mean size of the sac and neck was 16x10 mm and 5.3 mm, respectively. Four aneurysms were lobulated, and in these cases, the mean size of the sac and neck was 9x3 mm and 3.7 mm, respectively. The mean size of the proximal common carotid artery was 4.5 mm, and at the operation site, mean stenosis was 40%. CONCLUSION: In 10/14 cases (71%), we successfully established an aneurysm model in the porcine carotid artery, and believe that it is suitable for use in interventional neuroradiology experiments.

CT Findings of Enteric Fistula

Enteric fistulae result from gastrointestinal perforations in which communication is established between the site of perforation and another hollow viscus, potential space, or skin surface. Certain types of enteric fistulae are difficult to demonstrate by conventional radiographic methods, and CT is unique in its ability to demonstrate the extent and nature of extraluminal changes. The purpose of this study is to illustrate the CT findings of enteric fistulae occurring in a variety of abdominal and pelvic organs.

Introital Ultrasonography in Female Urinary Incontinence

PURPOSE: To evaluate the usefulness of introital ultrasonography in the assessment of female urinary incontinence. MATERIALS AND METHODS: Introital ultrasonography was performed in fifteen patients with stress urinasy incontinence(mean age 50) and six patients without symptoms of incontinence(mean age 37). Using a sagittalsection of the anterior pelvis in the plane of the symphysis pubib the posterior rethrovesical angle, the pubourethral distance and the pubo-yretgrak abgle were measured at rest and during stree(Valsalva's maneuverstate). The student T-test and the ANOVA test were used in statistical analysis. RESULTS: The posterior urethrovesical angles of the controls were 125.3 degrees (+/- 10.9) at rest and 125.7 degrees (+/-7.6) during stress. In thepatients, the corresponding angles were 135.3 degrees (+/-11.3) and 139.6 degrees (+/-10.8). The posterior urethrovesical angles increased 0.3 degrees (+/-4.7) in the controls and 5.6 degrees (+/-4.0) in the patients(p=0.018). In the controls, thepubo-urethral distances were 21.8mm(+/- 5.8) at rest and 18.2mm(+/-7.1) during stress, while in the patients thesedistances were 18.4mm(+/-3.9) and 12.6mm(+/-4.4). The pubo-urethra distance decreased 3.5mm(+/-1.5) in the controls and 5.8mm(+/-2.3) in the patients(p=0.039). In the patients with mild incontinence(Gradel), the posterior urethrovesical angles increased 3.4 degrees (+/-2.8) : 132.3 degrees (+/-12.5) at rest and 135.6 degrees (+/-12.8) during stress. In the patients with moderate incontinence(Grade II), the angles increased 8.1 degrees (+/-3.8) : 136.0 degrees (+/-6.5) at rest and 144.1 degrees (+/-5.9) during stress. The change of the posterior urethrovesical angle was related to the grade of urinary incontinence in the patients(p<0.05). There was no statistical significancy in the pubo-urethral angle(p=0.315). CONCLUSION: Introital ultrasonography may be useful for assessment of stress urinary incontinence.

Localized Fibrous Mesothelioma of the Liver: A Case Report

Localized fibrous mesothelioma of the liver is very rare benign tumor. It usually manifest large palpable hepatic mass in right upper quadrant area, and the prognosis is excellent by surgical resection. Contrast enhanced CT scan shows well defined hyperattenuating mass and celiac anglogram shows hypervascular mass. Recently we experienced 1 case of localized fibrous mesothelioma of the liver, and we report CT and anglographic findings of this tumor.