Outcome in lacunar stroke: A cohort study.

OBJECTIVES: We evaluated a prospective cohort of 150 patients under observation in our centre for lacunar strokes. The purpose of this study was to evaluate the outcome at time of discharge and 6 months after lacunar stroke, as well as the correlation with cardiovascular risk factors and selected biochemical parameters already evaluated on admission. Focus was to identify possible prognostic factors, which might be targeted through appropriate intervention concentrating on reduction in the incidence and impact of early clinical deterioration. METHODS: 150 patients with a lacunar stroke were included in the present study. A clinical 6-month follow-up was available for 98.7% of the patients. Infarcts were classified by size, shape and location. RESULTS: The most important predictors of high NIHSS score at time of discharge resulted NIHSS on admission (P < .001), leukocytosis (P = .013), in-hospital infections (P = .016) and size of lacunae (P = .005). Similarly, the most important predictors of poor outcome 6 months later were NIHSS on admission (P = .01), leukocytosis (P = .014), elevated CRP (P = .019), in addition to pre-admission Rankin (P < .001). CONCLUSION: Although infections are not causatively related to lacunar strokes, their prompt recognition and early treatment, control of inflammatory markers and fever are most important in influencing functional outcome in lacunar stroke.

Femoroacetabular impingement: role of imaging.

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427-1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412-1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264-272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head-neck junction and reduced depth of the femoral waist lead to abutment of the femoral head-neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage's extension.

Bone mineral density differences between femurs of scoliotic patients undergoing dual-energy X-ray absorptiometry.

AIM: To investigate whether a difference exists in the bone mineral density (BMD) between femurs in scoliotic patients undergoing dual-energy X-ray absorptiometry (DXA) and whether this difference is related to spine convexity. MATERIALS AND METHODS: Of 1080 consecutive patients who underwent DXA, 127 had lumbar scoliosis seen at DXA. Further, after excluding 30 patients with previous osteoporotic fractures, metallic/image artefacts, soft-tissue calcifications, the BMD differences between femurs of 97 scoliotic patients (94 females; mean age 67 ± 11 years) were analysed. Femurs were classified as ipsilateral or contralateral to the spine convexity. Least significant change was used as a threshold of measurement precision. Differences between femoral neck BMD in respect of and regardless of spine convexity were calculated for each patient. Student's t-test and Wilcoxon's signed-rank test were used to assess significance. RESULTS: Fifty-nine of 97 patients (61%) had left-sided scoliosis. Osteoporosis was found in 32/97 patients (33%), osteopenia in 54/97 (56%), and 11/97 (11%) had a normal T-score. Of 97 patients, 46 (47%) had ipsilateral BMD < contralateral BMD. Regardless of spine convexity, 66/97 patients (68%) had different BMD values between femurs. Among them, variation of densitometric diagnosis was seen in 29/66 patients (44%), and in 29/97 patients overall (30%). CONCLUSION: Differences in the femoral neck BMD exist between femurs of scoliotic patients undergoing DXA. Thus, bilateral femoral DXA acquisition is recommended.

Magnetic resonance imaging of painful total hip replacement: detection and characterisation of periprosthetic fluid collection and interobserver reproducibility.

PURPOSE: The purpose of our study was to demonstrate the diagnostic value of magnetic resonance imaging (MRI) when measuring and characterising periprosthetic fluid collections in patients with painful hip prosthesis and to provide an estimation of interobserver reproducibility. MATERIALS AND METHODS: Nineteen patients (mean age 59±13 years) with painful total hip replacement and clinical suspicion of infection underwent MRI. Images were reviewed blindly by two musculoskeletal radiologists with different levels of experience who evaluated the presence/absence of soft tissue oedema or fluid collection (when present, three-plane maximal diameters were measured; involvement of skin/subcutaneous/deep tissues or prosthesis were estimated; fluid was classified as serous/purulent/haematic according to signal behaviour). Interobserver agreement was calculated (Cohen's ). RESULTS: A total of 26 MRI studies were carried out (three patients underwent two and two patients underwent three MRI examinations). Both readers detected soft tissue oedema (13/26, 50%) or fluid collection (21/26, 81%) and characterised the fluid as serous (9/21, 43%), purulent (8/21, 38%) or haematic (4/21, 19%). The collection involved skin/subcutaneous tissues (16/21, 76%), deep soft tissues (19/21, 91%) or the implant (12/21, 57%). For all evaluations, interobserver agreement was complete (=1). No significant differences were found between the measurements of the collections (p>0.258). CONCLUSIONS: MRI is highly reproducible in detection, localisation, quantification, and characterisation of fluid collections when the presence of implant infection is clinically suspected.

Thunderclap headache and benign angiopathy of the central nervous system: a common pathogenetic basis.

Thunderclap headache (TCH) is a head pain that begins suddenly and is severe at onset; TCH might be the first sign of different neurological illnesses, and primary TCH is diagnosed when no underlying cause is discovered. Patients with TCH who have evidence of reversible, segmental, cerebral vasoconstriction of circle of Willis arteries and normal or near-normal results on cerebrospinal fluid assessment are thought to have reversible cerebral vasoconstriction syndrome (RCVS). Herein, we discuss the differential diagnosis of TCH and offer pathophysiological considerations for TCH and RCVS.

Myocardial delayed enhancement using a single dose (0.1 mmol/kg) of gadobenate dimeglumine: contrast resolution versus intraventricular blood and viable myocardium.

PURPOSE: This study was done to estimate delayed enhancement (DE) contrast resolution of infarcted myocardium (IM) relative to intraventricular blood (IB) and viable myocardium (VM) using gadobenate dimeglumine (Gd-BOPTA). MATERIALS AND METHODS: After approval from the Ethics Committee, we retrospectively evaluated 21 consecutive patients (61+/-10 years) with a healed myocardial infarction who underwent 1.5-T magnetic resonance (MR) imaging using an inversion-recovery-prepared turbo gradient-echo sequence 10 minutes after injection of 0.1 mmol/kg of Gd-BOPTA. Signal intensity (SI) was measured in arbitrary units (au) for IM, IB, VM, and outside the patient. Contrast-to-noise ratio (CNR) was calculated for IM to IB and IM to VM. Seven consecutive patients (59+/-6 years) with a healed myocardial infarction studied with similar technique but with 0.1 mmol/kg of gadoterate meglumine (Gd-DOTA) served as the control group. The Mann-Whitney U test was used to compare groups. RESULTS: Mean SI of IM was 44+/-16 au for Gd-BOPTA and 20+/-6 au for Gd-DOTA (p<0.001), that of IB 35+/-15 au and 14+/-5 au (p=0.016), and that of VM 7+/-3 au and 5+/-2 au (p=0.116), respectively. Mean IM to IB CNR was 10+/-7 for Gd-BOPTA and 8+/-5 for Gd-DOTA (p=0.836), that of IM to VM was 45+/-27 and 18+/-6, respectively (p=0.012). CONCLUSIONS: Gd-BOPTA at 0.1 mmol/kg produced a higher myocardial DE and an IM to VM CNR than a single dose of Gd-DOTA. No significant difference was observed for IM to IB CNR.

MR imaging of aortic coarctation.

Aortic coarctation accounts for 5%-10% of all congenital heart diseases and represents 7% of critically ill infants with heart disease. Magnetic resonance (MR) imaging allows the study of this disease with several advantages in comparison with conventional angiography, transesophageal echocardiography, and computed tomography. The MR protocol applied at our institution for both diagnosis and follow-up after surgical or endovascular treatment consists of four steps: morphologic study, cine MR study, flow analysis, and MR angiography (MRA). The first three sequences are acquired during breath-hold and with electrocardiographic gating. Anatomy is well depicted with dark-blood half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequences. Cine true-fast imaging with steady-state precession (true-FISP) sequences show not only morphologic features but also blood-flow changes inside the aorta. Gradient-echo sequences for phase-velocity mapping allow flow analysis. Application of Bernoulli's equation--here briefly presented and discussed--allows for calculation of the pressure gradient caused by the coarctation. MRA, acquired with a breath-hold three-dimensional T1-weighted gradient-echo sequence and intravenous administration of paramagnetic contrast material, allows for optimal depiction of the aortic lumen, with a panoramic view of the whole aorta, its main branches and possible collateral circulation.

MR imaging of the knee in patients with medial unicompartmental arthroplasty: comparison among sequences at 1.5 T.

PURPOSE: This study was done to test a series of magnetic resonance (MR) imaging sequences of the knee after medial unicompartmental arthroplasty. MATERIALS AND METHODS: Four patients who had undergone Oxford III medial unicompartmental arthroplasty underwent 1.5-T MR imaging of the operated knee using coronal sequences: T1-weighted spin-echo (SE), T1-weighted turbo SE (TSE), proton-density (PD)- and T2-weighted TSE, T1-weighted gradient echo (GE), short-tau inversion recovery (STIR), multi echo data image combination (MEDIC), T2*-weighted GE, volumetric interpolated breath-hold examination (VIBE), and dual-echo steady state (DESS). For each sequence, we evaluated the visibility of the anatomical structures of the central pivot, lateral compartment, and anterior compartment using a semiquantitative score (0=total masking; 1=insufficient visibility; 2=sufficient visibility; 3=optimal visibility). The sum of the scores given to each sequence was divided by the maximal sum, obtaining a percentage visibility index. Friedman and sign tests were used for statistical analysis. RESULTS: MR examination time was 30-32 min. No patients reported pain, heat or other local discomfort. The visibility index ranged between 83% and 89% for the first four sequences without significant differences among them, 58% for STIR and 11%-36% for the last five sequences. Significant differences were found between each of the four first sequences and the remaining sequences (p<0.004) and between STIR and the last five sequences (p<0.008). CONCLUSIONS: MR imaging of the knee after medial unicompartmental arthroplasty was not associated with adverse events. An imaging protocol including SE, TSE and STIR sequences could be used to study the knee with unicompartmental arthroplasty.

Supervised automatic procedure to identify new lesions in brain MR longitudinal studies of patients with multiple sclerosis.

PURPOSE: Identification of new enhancing lesions is a major endpoint of longitudinal brain magnetic resonance (MR) studies of multiple sclerosis (MS). To date, this is a visual, time-consuming procedure. We present here a supervised automated procedure (SAP) aimed at reducing the time needed to identify new MS enhancing lesions. MATERIALS AND METHODS: The SAP uses an algorithm including Cartesian coordinates of the lesions to be compared, their area and a constant (k). The procedure was validated for enhancing lesions on T1-weighted spin-echo images after intravenous administration of 0.1 mmol/kg of paramagnetic contrast agent, randomly selected from a dataset of a longitudinal MR study on ten relapsing-remitting MS patients followed for 2-5 years. During the validation session, two readers decided by consensus whether two lesions, present on the same slice of two examinations performed on subsequent dates, were the same or not. In this way, k was calibrated to obtain the same result from both visual inspection and automatic algorithm output. RESULTS: After evaluating of 25+/-5 (mean+/-standard deviation) lesions in each of ten different sessions with correction of k value, the k value became a stable value (0.45+/-0.05). CONCLUSIONS: Once the suitable value of k was found, SAP was able to identify new enhancing lesions, avoiding visual inspection, which is usually a lengthy procedure.

The value of chemical fat-saturation pulse added to T1-weighted spin-echo sequence in evaluating gadolinium-enhancing brain lesions in multiple sclerosis.

PURPOSE: This study was undertaken to assess the value of a chemical (spectral) fat-saturation (fat-sat) pulse added to a T1-weighted spin-echo sequence after intravenous administration of paramagnetic contrast agent in detecting enhancing lesions in multiple sclerosis. MATERIALS AND METHODS: Twenty patients with relapsing-remitting multiple sclerosis underwent a brain 1.0-Tesla magnetic resonance (MR) scan with T1-weighted spin-echo sequences (24 contiguous para-axial slices with a thickness of 5 mm, pixel size 0.96 mm(2), number of excitations 2, flip angle 90 degrees ) 5 min after intravenous injection of 0.1 mmol/kg of gadodiamide with and without fat-sat, acquired with randomised order of priority. Two readers counted by consensus the number of enhancing lesions and assigned a conspicuity score (low conspicuity=1; high conspicuity=2) to each enhancing lesion during a randomised reading without any visual comparison between the two corresponding images (with and without fat-sat) of the same patient. McNemar and Wilcoxon matched-pair signed-rank tests were used. RESULTS: Seventy-two enhancing lesions without fat-sat and 94 with fat-sat were detected; 22 lesions were visible only with fat-sat, whereas no lesion was detected only without fat-sat (p<0.0001). The conspicuity score was 1.17+/-0.38 (mean+/-standard deviation) and 1.57+/-0.44, respectively (p<0.0001). CONCLUSIONS: A fat-sat pulse added to a T1-weighted spin-echo sequence increases significantly the number and conspicuity of contrast-enhancing lesions in patients with relapsing-remitting multiple sclerosis.

Platelet glutamate uptake and release in migraine with and without aura.

Glutamate may play an important role in the pathogenesis of migraine: glutamate release in the brain may be involved in the development of spreading depression and increased concentrations of this amino acid have been reported in plasma and platelets from migraine patients. Here we assessed platelet glutamate uptake and release in 25 patients affected by migraine with aura (MA) and 25 patients affected by migraine without aura (MoA), comparing the results with a group of 20 healthy matched controls. Both glutamate release from stimulated platelets and plasma concentrations of the amino acid were assessed by high-performance liquid chromatography, and were increased in both types of migraine, although more markedly in MA. Platelet glutamate uptake, assessed as 3H-glutamate intake, was increased in MA, while it was reduced in MoA with respect to the control group. These results support the view that MA might involve different pathophysiological mechanisms from MoA and, specifically, up-regulation of the glutamatergic metabolism. Understanding these dysfunctional pathways could lead to new, possibly more successful therapeutic approaches to the management of migraine.

The complications of migraine with aura.

Migraine with aura is a common disorder in industrialised countries, affecting up to 5% of the adult population. Although migraine aura is usually a benign disorder, in rare instances it can be the cause of serious neurologic complications. The most common is migrainous stroke, defined as a persistent neurologic deficit following the aura with evidence of brain infarction at neuroimaging and lack of alternative explanations. The most likely pathogenic mechanism is brain ischaemia induced by cortical spreading depression, but other possibilities, such as intracranic arterial dissection or embolism through patent foramen ovale need to be considered. Other complications are migraine-related seizures, which are probably caused by neuronal hyperexcitability in migraineurs, and persistent auras without infarction. These disorders are of both clinical and scientific interest, as they throw light on the complex and not yet fully understood relationship between migraine with aura, stroke and epilepsy.

One-shot CT and MR arthrography of the shoulder with a mixture of iodinated and paramagnetic contrast agents using arthroscopy as a gold standard.

PURPOSE: Our aim was to perform computed tomography arthrography (CTA) and magnetic resonance arthrography (MRA) of the shoulder as a one-shot examination and to evaluate its value on the basis of arthroscopy as a gold standard. MATERIALS AND METHODS: Fifteen men and 16 women with planned arthroscopy for chronic (n=17) or traumatic tear of the rotator cuff (n=8), congenital atraumatic (n=1) or traumatic glenohumeral instability (n=2), traumatic tear of the rotator cuff with glenohumeral instability (n=1), or "frozen shoulder" (n=2) underwent plain helical CT in neutral position and intra-articular CT-guided injection of a mixture of iodinated and paramagnetic contrast agents (gadodiamide at 1:250 and iobitridol 350 at 1:5 in 20 ml of saline solution). CT helical scans in intra- and extrarotation and T1-weighted MRA scans in the neutral position were obtained. CTA and MRA were evaluated separately and jointly (CTA-MRA) in different blinded sessions, giving a 0-3 score to the agreement of CTA, MRA, and CTA-MRA with arthroscopy. RESULTS: The injected volume of the solution ranged from 10 to 24 ml. No side effects were observed. CTA obtained a score of 2.33+/-0.62, MRA 2.47+/-0.52, and CTA-MRA 2.67+/-0.49. Significant differences were found for CTA-MRA versus CTA (p=0.0281) and MRA (p=0.0277). There was no significant difference for CTA versus MRA. CONCLUSIONS: CTA and MRA can be performed as a one-shot exam. CTA-MRA seems to give more information than CTA or MRA separately.

Neuroradiological investigations in secondary headaches.

In this work, we examine the neuroradiologic features of the main non vascular clinical conditions responsible for secondary headache; excluding CSF hypotension, which will be treated extensively in another work in this supplement. Headache is not a constant feature of intracranial mass lesions, even of large extension. Headache has a high diagnostic value in children, as it can be the only heralding symptom, sometimes even for a long time, of severe intracranial pathologies, which later give rise to seizure or focal neurological signs. Particular attention should be paid to children affected by leukaemia under pharmacological treatment, in which headache is almost always the presenting symptom of serious neurological syndromes, consequent to antiblastic drugs.

MIDAS questionnaire in the emergency setting.

Migraine is a common disorder and is a major cause of disability and loss of working performance in western countries. Therefore, many tools have been developed to assess migraine related disability. Among these, the Migraine Disability Assessment (MIDAS) questionnaire has been shown to be of particular interest, as it is valid, reliable and useful for therapeutic decisions. In this pilot study, we address the validity of the MIDAS questionnaire in an unselected population of migraine patients in the emergency setting. We found that the MIDAS scores in the emergency room were similar to those collected in a specialised headache centre. This result suggests that the MIDAS questionnaire could be reliably used in the emergency setting, hence avoiding unnecessary delays in the treatment of migraine patients.

Deep brain stimulation for the treatment of Parkinson's disease: the experience of the Neurosurgical Department in Monza.

deep brain stimulation is a widely accepted surgical therapy for the symptomatic treatment of advanced parkinson's disease; high frequency chronic stimulation of the subthalamic nucleus proved its efficacy to control the major motor symptoms. In the neurosurgical department of Monza we treated 72 parkinsonian patients (November 1998-January 2003). One year follow-up results are: decrease of tremor 90%, hypertonous 56%, bradykinesia 70%, voice impairment amelioration 30%, mean total daily L-dopa intake reduced 58%. Freezing and balance did not ameliorate, some voice impairment and psychic derangement have been observed. Major surgical complications were: haemorrage (1 case - transient hemiparesis), infections (2 cases), pulmonary embolisation (1 case). To optimise the surgical results, careful clinical and instrumental selection of the patients are mandatory before surgery.

Increased glutamate in CSF and plasma of patients with HIV dementia.

BACKGROUND: Experimental evidence suggests that excitotoxicity might play a major role in HIV-induced neurodegeneration. However, few studies have investigated the role of endogenous glutamate in patients with HIV dementia. OBJECTIVE: To analyze CSF and plasma glutamate levels in 30 patients with AIDS with different dementia severity compared with 10 patients with other neurologic disorders, 11 healthy control subjects, and 10 patients with Alzheimer-type dementia. METHODS: CSF and plasma glutamate levels were measured by reverse-phase high-performance liquid chromatography followed by fluorometric analysis. RESULTS: Glutamate CSF levels were increased fivefold in the patients with HIV vs normal control subjects (p = 0.001), patients with Alzheimer-type dementia (p < 0.0001), and patients with other neurologic disorders (p < 0.01). CSF glutamate levels were also related to the degree of dementia (p < 0.02) and brain atrophy (p < 0.002). Plasma levels were also higher in the patients with HIV (p < 0.0001) but did not correlate with either clinical or imaging features. CONCLUSION: Increased CSF glutamate may originate within the CNS and may play a pathogenetic role in HIV dementia, thus supporting the treatment of these patients with glutamate receptor antagonists.