Combined accuracy of optic nerve sheath diameter, strain ratio, and shear wave elastography of the optic nerve in patients with idiopathic intracranial hypertension

Purpose@#This study assessed the combined accuracy of optic nerve sheath diameter (ONSD), strain ratio (SR), and shear wave elastography (SWE) of the optic nerve (ON) in patients with idiopathic intracranial hypertension (IIH). @*Methods@#This prospective study was carried out on both ONs of 34 consecutive patients diagnosed with IIH and 16 age- and sex-matched healthy volunteers. All of the study participants were women. The ONSD, SR, and SWE of the ON were measured. The severity of papilledema of IIH patients was sub-classified into mild papilledema and moderate/severe papilledema. @*Results@#The mean ONSD (5.6±1.1 mm), SR (0.7±0.1), and SWE (30.1±16.7 kPa) of the IIH patients were significantly different (P=0.001) from the ONSD (4.1±0.5 mm), SR (0.9±0.1), and SWE (8.2±3.4 kPa) of controls. The cutoff values of ONSD, SR, and SWE of the ON for differentiating IIH patients from controls were 5.45 mm, 0.8, and 10.3 kPa with areas under the curve (AUCs) of 0.91, 0.86, and 0.96 and accuracy values of 91%, 81%, and 93%, respectively. Combined SWE and ONSD and combined SWE, ONSD, and SR for differentiating IIH patients from controls revealed AUCs of 0.98 and 0.99 and accuracy values of 96% and 96%, respectively. ONSD, SR, and SWE showed significant differences between mild and moderate/severe papilledema (P=0.001). Papilledema was correlated with SWE (r=0.8, P=0.001), ONSD (r=0.4, P=0.001), and SR (r=-0.4, P=0.001). @*Conclusion@#The combination of ONSD, SR, and SWE may be helpful for diagnosing IIH, and a good indicator of the degree of papilledema.

impact of IFN beta 1a and IFN beta-1b on the clinical and MRI responses in patients with relapsing-remitting multiple sclerosis

Multiple Sclerosis [MS] is a common demyelinating and inflammatory disease of the CNS with a presumed autoimmune etiology. IFN beta-1a and IFN beta-1b have a proven treatment effect on RRMS presumably through its regulatory properties on T-cell activation and cytokines production. Here we studied the clinical and MRI effects of these drugs in four groups of clinically and laboratory [Cerebrospinal fluid evaluation revealed elevation of immunoglobulin [IgG] synthesis rate and oligoclonal bands] definite RRMS patients for 18 months. In IFN beta-1a group [n = 25], the patients used IFN beta-la 30 micro g [6MU] intramuscular once a week, the other three groups of IFN beta-1a [n = 25] 22 micro g [6MU], IFN beta-la 44 micro g [n = 25] and IFN beta-1b 8MU [0.25 mg] [n = 25] were injected subcutaneously 3-time a week. In comparison with the pre-treatment values, reduction in the relapse rate was statistically significant in IFN beta-la 44 micro g, IFN beta-la 30 micro g and IFN beta-lb 8MU groups more than IFN beta-la 22 micro g [P < 0.001, 0.008, 0.001 and > 0.5 respectively], and the mean EDSS significantly reduced in the IFN beta-lb [P < 0.001], IFN beta-la intramuscular [P < 0.02] and 44 micro g IFN beta-la [P < 0.001], in contrast to 22 micro g IFN beta-la treated patients [P > 0.5]. Moreover, IFN beta-lb [P < 0.001] and 44ug IFN beta-la [P < 0.003] groups showed highly statistical significant reduction in MRI disease activity load [p < 0.05] in comparison with 22micro g IFN beta-1a [p < 0.5] and IFN beta-la intramuscular groups [p < 0.07]. The study confirmed also the effect of beta-IFNs on the short term physical disability scale [p < 0.01] while they have no significant effect on long term disability scale [p > 0.64]. Additionally, beta-IFNs groups showed no statistically significant severe drugs adverse effects [p > 0.8] while revealed significant effects of recovered side effects [p < 0.01]. The common adverse effects of lFN beta that were significantly found [p < 0.01], are flu-like symptoms, fatigue, chills and fever, injection site pain and local redness, headache, irregular menses and mild depression specially with IFN beta-la intramuscular. No difference in the clinical suspicions of binding antibodies development to beta-IFNs was found. On the whole, all groups showed significant reduction of relapse frequency and MRI load with different values [p < 0.01]. In summary, this study does make available meaningful and helpful clinical and radiological data to the clinician regarding the relative efficacy of each therapy in RRMS. First, the results of our study suggest that IFN beta-lb 8MU and IFN beta-1a 44 micro g may be more optimal choices than IFN beta-la 30 micro g Intramuscular and IFN beta-la 22 micro g at the currently available dose in treatment of RRMS patients. Secondly, the results do not differ from remarks made after 18 months of treatment in larger and more rigorously controlled studies. Thirdly, therapy does construct a difference and early treatment should be encouraged

Migraine and patent foramen ovale: transesophageal echocardiography study. should we exclude migraine without aura?

The prevalence and size of patent foramen ovale [PFO] in migraine without aura have never been assessed directly using Transesophageal echocardiography [TEE] and compared with migraine with aura. We sought to assess the prevalence and the size of patent foramen ovale in patients suffering from migraine with [MA] and without [MoA] aura using TEE. consecutive patients with migraine with and without aura were asked to participate in the study. Impact of migraine on daily life was assessed using the Migraine Disability Assessment [MIDAS] questionnaire. Contrast transesophageal echocardiography was performed to all participants and the presence of a patent foramen ovale and their size were assessed. forty consecutive patients with migraine headache were included in our study. The majority of participants were women, mean age was 26.7 [18-38 year]. Family history of migraine was encountered in 65% of patients. The mean Migraine severity using MIDAS was 16.2 [5-28] half of the patients were higher than the score of 21. Out of the 40 studied patients, 18 [45%] showed patent foramen ovale in TEE examination. Twenty patients [50%] had migraine with aura. There was no statistical difference between MA and MoA patients regarding age, sex, and MIDAS. The prevalence of patent foramen ovale was significantly higher in MA patients 11 out of 20 [55%] compared with 7 out of 20 [35%] MoA patients [OR 2.7, p = 0.005]. The presence of PFO was significantly related to the migraine disability severity score. Large PFO size was found in 45% of patients with MA while 42% of patients with MoA [p = NS]. although prevalence of PFO is higher in migraine with aura, the prevalence of large PFO is nearly the same in both subtypes of migraine and more related to severity of migraine disability and family history of migraine

Selective amygdalohippocampectomy for temporal lobe epilepsy management

Epilepsy surgery has a proven treatment effect on patients with medical intractable partial seizures, presumably through its resection of epileptogenic zone. This prospective and nonrandomized controlled study examines whether minimal invasive microneurosurgical interventional through frontolateral trans-sylvian approach for a high selective amygdalohippocampectomy would reduce the frequency of epilepsy and antiepileptic drugs [AEDS], for patients who have had long history of poor response on pharmacotherapy, via measuring over one year the clinical, activity of daily living and EEG outcomes. Our inclusion/ exclusion criteria for selected cases and according to the definition of ILAE are, intractable temporal lobe epilepsy [TLE] either right or left side origin, all patients had a history of treatment for more than 13 years by AEDS polytherapy and according to our inclusion criteria they should have at least 4 seizures a month. Selective amygdalohippocampectomy was done for 17 patients and all of them were followed up for one year. The study confirmed that selective amygdalohippo-campectomy reduces the seizures frequency and drugs doses in patients with mesial temporal lobe epilepsy [MTS]. However, amygdalohippocampectomy did not signify cessation of all AEDS, but all patients showed satisfactory seizure free outcome under monotherapy. There is also significant difference in epilepsy frequency postoperatively especially psychomotor component. The findings are important for the understanding of selective amygdalohippocampectomy role in the treatment of intractable TLE [MTS] with or without secondary generalization

Role of apparent diffusion coefficient (ADC) and multivoxel chemical shift proton spectroscopy in grading of brain tumors

Background and Purpose: Grading of brain tumors carries great importance in its evaluation and management. The aim of this work was to evaluate the role of apparent diffusion coefficient [ADC] and multivoxel chemical shift proton spectroscopy in grading of various brain lesions

Subjects and Methods: This study was conducted on 35 patients with brain tumors [11 high grade and 7 low-grade glioma, 7 metastases, 6 meningiomas, and 4 tuberculomas]. They presented with various combinations of neurologic manifestations [headache [24 patients], convulsions [11], focal neurologic deficits [27] and altered sensorium [6]]. They were prospectively evaluated with contrast material-enhanced MR imaging, multi-voxel proton MR spectroscopy [TE = 270 ms], and diffusion-weighted imaging [b = 0, 500, and 1000 s/mm2] before surgery

Results: MR spectroscopy could differentiate benign from malignant tumors but was not useful in grading malignant tumors. In the differentiation of malignant from benign tumors, N-acetylaspartate [NAA]/choline [Cho] and Cho/ creatine [Cr], ratios [P < 0.001] were statistically more significant than NAA/Cr. Lipid and lactate peacks were detected in 8 cases of high grade glioma and 6 cases of matastases but was not detected in any case of low grade glioma. ADCs were effective for grading malignant tumors [P < 0.001] but not for distinguishing different tumor types with the same grade. High-grade malignant tumors [0.85+8 x 10-3 mm2/s] had significantly lower ADC values than did low-grade malignant [1.15 + 9 x 10-3 mm2/s] and benign [1.08 + 12 x 10-3 mm2/s] tumors. Peritumoral ADCs were insignificant in differentiation between high and lowgrade glioma as well as between edema and non enhanced peritumoral infiltration

Conclusion: Combination of calculated ADC values from tumoral core and specific relative metabolite ratios acquired by MR spectroscopy added more information to MR imaging in the differentiation and grading of brain tumors

Usefulness of CHO / CR ratio in MR spectroscopy in differentiation between recurrent brain tumor and radiation necrosis

The aim of this study was to evaluate the role of cho/cr ratio in MR spectroscopy [MRS] in differentiation between recurrent tumor and radiation necrosis in equivocal brain lesions following radiotherapy for brain tumors. Hydrogen [1H] MR spectroscopy was performed for 17 patients presented with recent neurological manifestations and / or their CT or MRI examination revealed an equivocal brain lesion during follow up after completion of radiotherapy for brain tumor [gliomas [12], medulloblastoma [3] and ependymoma [2]]. Volume of interest [VOI] was placed inside the lesion in T2 WIs [high SI] using single voxel spectroscopy in 7 patients and chemical shift for 10 patients according to the size and homogenecity of the lesion.Ratios of peak areas under the choline [Cho] and creatine [Cr] resonance were estimated in all cases and compared with those from samples of normal brain tissue. The Cho/Cr ratios in cases of tumor recurrence [1.5 +/- 0.6] were elevated compared to those in normal brain tissue while there was a reduction of Cho/Cr ratio [0.4 +/- 0.3] in radiation necrosis compared to normal brain. We also reported an obvious increase of Cho/Cr ratio in tumor recurrence than radiation necrosis. Cho/Cr ratio in MR Spectroscopy represents a recent helpful modality to differentiate between tumor recurrence and radiation necrosis in follow up of brain tumor patients after completion of radiotherapy

Three dimensional conformal radiotherapy [3-D crt] for non-functioning pituitary tumors

Introduction: Although pituitary adenomas are histologically benign, the unrelated neurological and physiological consequences can be devastating. Pituitary adenomas are common lesions and represent 10 to 20% of all primary brain tumors. Non-functioning pituitary adenomas comprise approximately 30% of all pituitary tumors. Modern radiotherapy technique, as three dimensional conformal radiotherapy [3-D CRT], have shown efficacy in all aspects of treatment with better immobilization, imaging, planning and treatment. Improvements aim to reduce normal tissue irradiation whilst preserving dose to the target

Methods: Fifty patients with residual or recurrent non functioning pituitary adenoma [29 male, 21 females]; median age 54 years [range 26-76 years], were treated with 3D-CRT at the Alexandria armed forces Hospital between June 2002 and June 2005. All patients had nan-functioning pituitary adenomas. Thirty-two patients with large residual tumor following primary surgery received 3D-CRT. Eighteen patients were treated at a later time following evidence of tumor recurrence. All patients were treated to a total dose from 45 to 54Gy. Most of the patients had six-fzeld technique using computer based 3-D CRTplanning. All tumors were > 1 cm and typically 3-4 cm superiar-inferior dimension

Results: Forty-six patients [92%] experienced continuous regression or stabilization of their tumors. Only four patients showed progressive disease. Patients with symptoms related to mass effect did well. A total of 19 of 24 patients with visual impairment and 17 of 18 with headache improved. All patients with cranial nerve palsies secondary to cavernous sinus compression also improved. Both early and late side effects occurred as results of radiation, which were mostly manageable

Conclusion: The results showed the efficacy of three-dimensional conformal radiotherapy to a dose from 45 to 54 Gy for pituitary adenomas from the standpoint of both clinical outcomes and imaging. F urther study of the neurocognitive sequelae of limited field irradiation to the pituitary region is needed as well as a prolonged follow up period to consolidate results

Epidemiological and clinical study of Kawasaki disease in a tertiary hospital in Makkah

This study involved 36 Kawasaki Disease patients diagnosed during the period from September 2000 to August 2004 at Al-Noor Specialist Hospital, Holy Makkah. Collected data included clinical features, laboratory results, echocardiogram findings, treatment, complications, and outcome. The average of 9 patients were diagnosed yearly, their age ranged from 6 months to 11 years and male to female ratio was 3.5:1. The clinical presentations were fever, skin rash and oral mucosa abnormalities [100%], desquamation of finger tips [88%], edema of palms and soles [77%], conjunctivitis [66%], and cervical lymphadenopathy [58%]. Seventy eight percent of cases presented in the summer and spring. Laboratory data showed leucocytosis, thrombocytosis, and high ESR. Echocardiography showed left coronary artery dilatation in 15 patients [42%], 10 of them [28%] had also right coronary artery dilatation. Coronary artery lesions had regressed in 11 cases [31%], while 4 patients [11%] progressed to giant aneurysms. Intravenous immunoglobulins [IVIGs] and aspirin were given. Neither cardiac dysfunction, nor valvular affection was observed; also, no recurrence and none died. In conclusions; although Kawasaki disease is a rare disease, 36 cases were diagnosed in Holy Makkah in 4 years, 4 of them progressed to giant coronary artery aneurysms. Increased awareness of the disease could help in early diagnosis and treatment and lower the rate of complications