A randomized comparison of efficacy and safety of intralesional triamcinolone injection and clobetasol propionate ointment for psoriatic nails.

BACKGROUND: Even though the traditional therapy for nail psoriasis has been used for decades, no randomized, controlled trial of such treatment has been conducted to date. OBJECTIVE: To evaluate the efficacy and safety of intralesional triamcinolone injections compared with 0.05% clobetasol ointment for psoriatic nails. MATERIALS AND METHODS: Psoriasis patients, each with three fingernails with similar degrees of severity, were randomly recruited for intralesional triamcinolone injection group, 0.05% clobetasol ointment group, and a control group. The target Nail Psoriasis Severity Index (NAPSI) score of each finger was evaluated, any adverse effects were recorded, and photographs were taken. RESULTS: Forty-eight affected nails were analyzed. At the second month, a significantly greater reduction of the target NAPSI score was observed in the injection group compared to the control group (p = .003). There was a greatest reduction of the score in the following two month-period, which showed significant difference from the topical group (p = .003) and the control group (p = < .001). The score of the injection group, however, subsequently rose at the six-month visit so that there was no longer any statistically-significant difference between the three groups. CONCLUSIONS: In spite of its temporary effect, the intralesional triamcinolone injection is an effective and safe treatment for psoriatic nails.

Predictors of Abnormal Neuroimaging of the Brain in Children With Epilepsy Aged 1 Month to 2 Years: Useful Clues in a Resource-Limited Setting.

Neuroimaging should be performed on infants with seizure. However, there are economic limitations in performing neuroimaging in a resource-limited setting. The younger the age, the higher the risk of having abnormal neuroimaging. The aim was to determine frequency and predictors of abnormal neuroimaging in children with epilepsy aged 1 month to 2 years. History, physical examination, electroencephalogram (EEG), and neuroimaging were reviewed. Thirty-seven of 49 (76%) had neuroimaging studies; 19 computed tomography (CT), 14 magnetic resonance imaging (MRI), and 4 had both. Abnormal neuroimaging was found in 19 (51%). Predictors of abnormal neuroimages are developmental delay, abnormal head circumference, and abnormal neurologic examination. Eight children (21%) had lesions on neuroimaging studies that altered or influenced management. Of 8 patients with normal examination and EEG, 1 had a brain tumor and another had arteriovenous malformation. Neuroimaging should be considered as an essential aid in the evaluation of infants with epilepsy, even in a resource-limited setting.

Neoplastic meningitis: a retrospective review of clinical presentations, radiological and cerebrospinal fluid findings.

OBJECTIVE: To review the clinical, radiological, and laboratory presentations of patients with neoplastic meningitis. MATERIAL AND METHOD: Patients with neoplastic meningitis were recruited by a retrospective search of cerebrospinal fluid (CSF) cytopathological report database of Siriraj Hospital between 1997 and 2006. Clinical information and CSF result of these patients were extracted from their medical records. Neuroimagings were reviewed by a neuroradiologist. RESULTS: The present study revealed 40 cases of neoplastic meningitis, which comprised of 17 cases with carcinomatous meningitis (CM) and 23 lymphoma/leukemia meningitis (LM) cases. In patients with CM, the majority (70%) had adenocarcinoma of lung or breast. Three of 17 cases with unknown primary tumor had carcinomatous meningitis as an initial presentation. In LM most of the cases (70%) were diagnosed with acute lymphoblastic leukemia (ALL) and non-Hodgkin's lymphoma (NHL). The most common symptom among patients with CM and LM was headache follow by cranial nerve palsy. In CM cases, CSF cytology was positive in the first specimen in 15 cases (82.35%) and in 22 from 23 cases (95.7%) in LM cases. Overall CSF showed pleocytosis in 36 cases (90%), most of which were lymphocyte predominant. The most common findings from brain imagings were leptomeningeal enhancement and hydrocephalus. CONCLUSION: The common primary sites were lung and breast cancer in the CM group and ALL and NHL in the LM group. The common symptoms were headache and cranial nerve palsy. Routine CSF examination was abnormal in virtually all cases. Positive CSF cytology was a gold standard for a diagnosis of leptomeningeal metastasis. High index of suspicious and awareness were required to avoid miss diagnosis.

Retrospective study of patients with herpes simplex encephalitis and positive CSF PCR.

OBJECTIVE: To determine the clinical presentations, laboratory and imaging findings of patients with HSE and positive CSF PCR then compare these with information from other viral encephalitis patients in order to find clinical clues that might help clinicians in early diagnosis and treatment of HSE while awaiting for the CSF PCR result. MATERIAL AND METHOD: A patient group with both HSE and positive CSF PCR and a control group of patients with other viral encephalitis were identified from Siriraj Hospital database within the period of 1997-2006. Medical notes of these patients were reviewed and relevant information, including clinical, laboratory and imaging study, were extracted. Then, descriptive statistics, unpaired t-test and Fisher's exact test were performed with the purpose to determine any clinical or laboratory clues that are significantly different between these two groups, which might help clinicians in making an early diagnosis of HSE. RESULTS: Seven HSE cases and 22 cases in control group were included. Fever, headache, alteration of consciousness, behavioral change, neck stiffness are the most commonly found clinical presentations in HSE patients with CSF PCR positive. CSF examination show CSF leukocytosis with lymphocyte predominate, decreased CSF:blood glucose ratio and elevated CSF protein in all cases. However, no single clinical or laboratory finding helps in differentiating HSE with positive CSF PCR from other viral encephalitides, except radiological abnormalities of temporal lobe, which yields a positive predictive value of 0.5 and a negative predictive value of 0.93. CONCLUSION: Our study showed that HSE shares common clinical and laboratory findings with other viral encephalitides, except for temporal lobe involvement. Early diagnosis is important and empirical acyclovir should be commenced early in patients with viral encephalitis, especially for those with radiological abnormalities on the temporal lobe.

Does magnetic resonance imaging give value-added than bone scintigraphy in the detection of vertebral metastasis?

OBJECTIVE: To determine the role of Magnetic Resonance (MR) imaging for the investigation ofpatients with suspected metastasis to the spine by bone scintigraphy. MATERIAL AND METHOD: Retrospectively reviewed with comparison was made between Technetium-99m Methylene Diphosphonate (99(m)Tc-MDP) bone scintigraphy and corresponding spine MR images in 48 cases of vertebral metastasis at Siriraj Hospital. The intervals between bone scintigraphy and MR images did not exceed 1 month. The authors studied between January 2005 and December 2006 Bone scintigraphy were performed with planar imaging of the entire body and MR imaging was performed with the 1.5 tesla and 3.0 tesla scanner using standard techniques with T1-, T2-weighted images and fat-suppressed T1-weighted images with intravenous administration of gadopentetate dimeglumine. The MR imaging findings were studied: location (cervical or thoracic or lumbar or sacrum spine), number of lesions (solitary or multiple lesions), pattern of enhancement (homogeneous or inhomogeneous), involvement of spinal canal, compression of spinal cord, extradural extension, other incidental findings such as pulmonary metastasis, pleural effusion, lymphadenopathy The final diagnosis was confirmed clinically and followed-up for further management (radiation or surgery) or followed-up by MR imaging (1 month-16 months) and bone scintigraphy (5 months-12 months). RESULTS: Forty-eight cases (80 lesions) of vertebral metastasis were identified (25 men and 23 women; mean age 61 years and range 8-84 years). Primary neoplasms include breast cancer (n=11), colorectal cancer (n=7), lung cancer (n=6), prostate cancer (n=5), nasopharyngeal cancer (n=5), head and neck cancer (n=3), thyroid cancer (n=2), liver cancer (n=2), esophagus cancer (n=1), bladder cancer (n=1), retroperitoneum cancer (n=1), medulloblastoma (n=1), cervical cancer (n=1), ovarian cancer (n=1), malignant melanoma (n=1). The result of bone scintigraphy and MR imaging is used to evaluate vertebral metastasis: in 44 lesions of bone scintigraphy positive for vertebral metastasis, 40/44 lesions (91%) which MR imaging reveal vertebral metastasis. This group may not benefit for further investigation by MR imaging. In 24 lesions of negative of bone scintigraphy for vertebral metastasis, the authors found that 14/24 lesions (58%) showed positive of vertebral metastasis from MR imaging. In this group, the authors recommended a further investigation because 58% of negative bone scintigraphy lesions are depicted by only MR imaging. MR imaging demonstrated metastatic cord compression in 16 cases. Extradural extension causes spinal canal narrowing in 30 cases. CONCLUSION: The authors conclude that the MR imaging is more efficient than the bone scintigraphy in detecting vertebral metastasis, especially in the cases that bone scintigraphy are equivocal or negative for vertebral metastasis in high clinical suspicion. Furthermore, MR imaging is important for the further treatment planning such as radiation therapy or systemic chemotherapy. Although MR imaging is useful in the detection of early metastasis that are localized completely in the bone marrow cavity routinely bone scintigraphy remains that most cost-effective method for examination of the entire skeleton.

Benign versus malignant compression fracture: a diagnostic accuracy of magnetic resonance imaging.

OBJECTIVE: To evaluate the accuracy, sensitivity, and specificity of various Magnetic Resonance Imaging (MRI) features in differentiating malignant from benign compression fracture of the spine. MATERIAL AND METHOD: Retrospective review of MRI spine of patients with vertebral compression fracture identified from the hospital database between June 2004 and February 2006 by two radiologists blinded to the clinical data. Various MRI features were evaluated for sensitivity, specificity, positive predictive value, and negative predictive value. An additional combination of two, three, four, and five MRI features that had statistically significant (P value less than 0.005) were also calculated for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Fifty-eight spinal MRI were included from 35 patients with metastatic vertebral compression fractures and 23 patients with benign vertebral compression fractures. MR imaging features suggestive of malignant vertebral compression fracture were convex posterior border of the vertebral body, involvement of the pedicle or posterior element, epidural mass, paraspinal mass, and destruction of bony cortex. Among these, involvement of pedicle or posterior element was the most reliable finding (sensitivity 91.4% and specificity 82.6%) for diagnosis of malignant vertebral compression fracture. A combination of two or more MRI features gave very high specificity and PPV. CONCLUSION: Certain MR imaging characteristics can reliably distinguish malignant from benign compression fracture of the spine. Combination of several MRI features strongly affirmed the diagnosis of malignant compression fracture, especially in a patient where tissue biopsy is not justified.

Computed tomographic findings in non-traumatic hemorrhagic stroke.

OBJECTIVE: To analyze CT findings in hemorrhagic stroke patients correlation with clinical outcome and assess the interobserver agreement of hemorrhagic stroke identification on CT imaging. MATERIAL AND METHOD: CT imaging features of 131 cases and clinical data were verified and collected at Siriraj Hospital from Jan 2004 to Dec 2005 and retrospectively analyzed for type, location, mass effect, size of hemorrhage, intraventricular extension, initial level of consciousness (GCS), hospital length of stay and patient outcome. The percentages, predictive values, kappa were calculated. RESULTS: From all types of hemorrhagic stroke, intracerebral hemorrhage remains a common and devastating clinical problem. The most common site was the thalamus and basal ganglia. In the present study, the authors found that fifty-three cases (53/131 cases, 40.5%) with thalamic-ganglionic hemorrhage, nineteen cases (19/131 cases, 14.5%) in lobar hemorrhage, five cases (5/131 cases, 3.8%) in cerebellum, five cases (5/131 7 cases, 3.8%) in brainstem and eight cases (8/131 cases, 6.1%) occurred in multiple locations. There were twenty-five cases (25/131 cases, 19.1%) of subarachnoid hemorrhage, thirteen cases (13/131 cases, 9.9%) of subdural hemorrhage and three cases (3/131 cases, 2.3%) of intraventricular hemorrhage. Two variables on CT imaging, identified as significant as early mortality predictors, were hematoma volume more than 60 cm3, and presence of intraventricular hemorrhage extension (p < 0.05). The mass effect defined as midline and/or enlargement of contralateral ventricle was not significant (p = 0.067). The present study found concordance between CT brain interpretation by two neuroradiologists for the type of hemorrhagic stroke was very good, Kappa = 0.861 as well as for location was 0.866. CONCLUSION: CT imaging is an imaging instrument for early identification of hemorrhagic stroke patients and providing imaging evidence of high mortality risk.

Low-grade gliomas: do changes in rCBV measurements at longitudinal perfusion-weighted MR imaging predict malignant transformation?

PURPOSE: To prospectively perform longitudinal magnetic resonance (MR) perfusion imaging of conservatively treated low-grade gliomas to determine whether relative cerebral blood volume (rCBV) changes precede malignant transformation as defined by conventional MR imaging and clinical criteria. MATERIALS AND METHODS: All patients gave written informed consent for this institutional ethics committee-approved study. Thirteen patients (seven men, six women; age range, 29-69 years) with biopsy-proved low-grade glioma treated only with antiepileptic drugs were examined longitudinally with susceptibility-weighted perfusion, T2-weighted, fluid-attenuated inversion recovery, and high-dose contrast material-enhanced T1-weighted MR imaging at 6-month intervals to date or until malignant transformation was diagnosed. Student t tests were used to determine differences in rCBV values between "transformers" and "nontransformers" at defined time points throughout study follow-up. RESULTS: Seven patients showed progression to high-grade tumors between 6 and 36 months (mean, 22.3 months), and disease in six patients remained stable over a period of 12-36 months (mean, 23 months). Transformers had a slightly (but not statistically significantly) higher group mean rCBV than nontransformers at the point of study entry (1.93 vs 1.31). In nontransformers, the rCBV remained relatively stable and increased to only 1.52 over a mean follow-up of 23 months. In contrast, transformers showed a continuous increase in rCBV up to the point of transformation, when contrast enhancement became apparent on T1-weighted images. The group mean rCBV was 5.36 at transformation but also showed a significant increase from the initial study at 12 months (3.14, P = .022) and at 6 months (3.65, P = .049) before transformation. Rates of rCBV change between two successive time points were also significantly higher in transformers than in nontransformers. CONCLUSION: In transforming low-grade glioma, susceptibility-weighted MR perfusion imaging can demonstrate significant increases in rCBV up to 12 months before contrast enhancement is apparent on T1-weighted MR images.

Diagnostic accuracy of MR imaging in tuberculous spondylitis.

OBJECTIVE: To systemically evaluate MR imaging features of tuberculous spondylitis and to find features that may help differentiating tuberculosis from other spinal diseases. MATERIAL AND METHOD: Retrospective review of 65 MR imaging of two groups of patients between January 2002 and December 2005. Thirty-one patients were diagnosed as tuberculosis spondylitis and the rest were a randomly selected group of 34 patients with other spinal diseases. All images were reviewed by two neuroradiologists blinded to clinical data. Sensitivity and specificity of each MR imaging features were calculated. RESULTS: Three most useful MR imaging features with high sensitivity and specificity (> 80%) were endplate disruption (100%, 81.4%), paravertebral soft tissue (96.8%, 85.3%), and high signal intensity of intervertebral disc on T2W (80.6%, 82.4%). High sensitivity but low specificity signs in MRI included bone marrow edema (90.3%, 76.5%), bone marrow enhancement (100%, 42.5%), posterior element involvement (93.5%, 76.5%), canal stenosis (87.1%, 26.5%), and spinal cord or nerve root compression (80.6%, 38.2%). Low sensitivity but high specificity features in MRI were intervertebral disc enhancement (63.3%, 84.2%), vertebral collapse (58.1%, 85.3%), and kyphosis deformity (67.7%, 82.4%). Overall, the sensitivity and specificity of MRI for spinal tuberculosis were 100% and 88.2% respectively. CONCLUSION: The authors presented three good to excellent sensitivity and specificity MR imaging features for spinal tuberculosis, end plate disruption, paravertebral soft tissue formation, and high signal of intervertebral disc on T2W. In contrast to a previous study, most of the presented cases still presented with classic radiological pictures of "two vertebral disease with the destruction of the intervertebral disc". Only a small portion of the patients revealed sparing intervening disc or isolated single vertebral body involvement, which possibly reflected the early stages of the disease process.

Clinical and radiological features of childhood cerebral infarction following varicella zoster virus infection.

The aim of the study was to describe the clinical and radiological features of childhood post-varicella cerebral infarction (PVCI). A retrospective review was undertaken of children with arterial ischaemic stroke (AIS) who had experienced varicella zoster virus (VZV) infection within the preceding year. Twenty-four children (15 males, nine females; age range at time of VZV infection 2mo-6y) were identified, with a median of 4 months between VZV and AIS (range 1wk-12mo). All had infarction in the middle cerebral artery (MCA) territory and abnormalities of the M1 segment; arteriopathy affected other arteries in 10 children. After a median of 27 months, six patients had recurrent transient ischaemic attacks (TIA), with new infarcts in two of 22 children on re-imaging. Arterial disease improved in 11 children, was stable in four, and progressed in seven (of whom four had recurrent TIA and two had re-infarction). PVCI affects young, previously healthy children within a few months of VZV infection and is characterized by MCA territory infarction and proximal MCA disease. One quarter of patients have recurrence, usually, but not inevitably, associated with progressive arteriopathy. Treatable co-existing AIS risk factors should always be excluded. A more comprehensive diagnostic evaluation should be considered in children with AIS who do not fit the clinical and radiological profile outlined, even where there is a history of recent VZV infection.

Apparent diffusion coefficient histograms may predict low-grade glioma subtype.

The subtypes of glioma are known to have different prognosis and response to treatment. The purpose of this work was to investigate whether apparent diffusion coefficient (ADC) histograms of untreated low-grade astrocytomas and oligodendrogliomas exhibit different characteristics due to their biological differences, and whether a diagnosis of tumour subtype can be made at presentation using the histogram alone, which, if possible, would have an impact on clinical practise. Fifteen patients with astrocytoma (AC) [11 male (mean age +/- standard deviation) 40 +/- 11 years], nine with oligodendroglioma (OD) (four male, 45 +/- 13 years) and three with oligoastrocytoma (OA) (two male, 60 +/- 11 years) were recruited and diffusion-weighted images (b = 0 and 1000 s mm(-2)) were acquired every 6 months to date or until malignant transformation. Whole tumour ADC histograms were calculated, a multiple discriminant analysis was performed and quantitative morphological parameters extracted, the AC and OD subtypes were then compared using Student's unpaired t-test. Classification of the histograms was also performed. ODs had significantly lower group ADC values than ACs and up to 83% of the subjects could be correctly classified into the OD and AC groups by reference to the histogram. The group differences were most significant for the multiple discriminant analysis (p = 1 x 10(-5)) and at the 10th centile point [AC = 1170 +/- 170, OD = (1030 +/- 80) x 10(-6) mm(2) s(-1)] (p = 0.01). ODs have a lower ADC than ACs with differences throughout the histogram. Both tumour types show similar intra-tumour heterogeneity, as seen from the equal group peak heights, but ACs shows more intra-group heterogeneity. ADC histogram analysis may aid non-invasive sub-classification of low-grade glioma histological subtypes.

Evolution of cerebral arteriopathies in childhood arterial ischemic stroke.

OBJECTIVE: To investigate evolution of cerebral arteriopathy in children with arterial ischemic stroke (AIS) and its influence on recurrence. METHODS: Arteriopathy severity was graded on serial magnetic resonance angiograms from 50 children with first AIS; diagnostic categories were assigned. RESULTS: Arteriopathy affected 72 arteries in 43 of 50 children. Five had clinical recurrence, with reinfarction in four; another had clinically silent reinfarction. Twelve children (24%; 4 with recurrence) had progressive arteriopathy. Arteriopathy improved in 24 patients (including 1 with recurrent transient ischemic attacks) and was stable in 7 patients. Magnetic resonance angiograms remained normal in seven patients; one had recurrent stroke. Diagnoses were transient cerebral arteriopathy (n = 24), chronic cerebral arteriopathy (n = 11), arterial dissection (n = 3), possible moyamoya (n = 2), primary moyamoya (n = 1), dysplastic arteriopathy (n = 1), and cerebral vasculitis (n = 1). Some of the first two categories could represent thromboembolic arterial occlusion with recanalization. The hazard of recurrence was three times higher when arterial disease had progressed (Cox regression hazard ratio, 3.2; 95% confidence intervals, 0.5-20.3; p = 0.22). After adjustment for age and number of AIS risk factors, the hazard ratio was 3.1 (95% confidence interval, 0.4-22.2; p = 0.27). INTERPRETATION: Arteriopathy frequently progresses after childhood AIS. Further studies are needed to examine the relationship between progressive arteriopathy and recurrence.

Post-varicella intracranial haemorrhage in a child.

We report a case of a 7-month-old male with primary intracranial haemorrhage 2 months after infection with varicella zoster virus (VZV). His initial clinical course was complicated by seizures and right hemiparesis; when last seen at 22 months the only positive finding was of left hand preference. Although the literature has recently established the association of arterial ischaemic stroke and VZV infection, primary intracranial haemorrhage has been reported only in one case. The child reported here had anterior interhemispheric haemorrhage due to a focal arteritis of the left anterior cerebral artery. The vascular abnormality was transient and had radiological features compatible with either a focal arteritis or vasospasm as a direct result of blood surrounding the vessels. We postulate that direct invasion of VZV caused extensive inflammation of the vessel wall and aggressive tissue penetration resulting in necrotizing angiitis and intracranial haemorrhage. We suggest that VZV infection should be considered a potential risk factor for intracranial haemorrhage in children.

Cerebello-Pontine angle (CPA) lymphoma with perineural extension into the middle fossa: case report.

BACKGROUND: Tumors of the cerebello-pontine angle are most commonly schwannoma and meningioma. Primary central nervous system (CNS) lymphoma usually presents deep within the cerebral hemispheres, occasionally is found in the cerebellum, and rarely occurs in the cerebello-pontine angle. We report a rare case of primary CNS lymphoma involving the right cerebello-pontine angle and the middle cranial fossa mimicking a tentorial meningioma. METHODS: A 21-year-old woman presented with right sided hearing loss and a facial droop. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed, followed by cerebral angiography to assess vascularity. RESULTS: Imaging revealed a bilobed mass involving the right cerebello-pontine angle and middle fossa. The labyrinthine segment of the facial nerve canal was enlarged, and some bony erosion was seen along the petrous bone anteriorly. The mass was hypointense on both T1 and T2-weighted MRI and exhibited heterogenous enhancement. It was distinctly hypovascular on angiography. At surgery, a B-cell lymphoblastic lymphona was found that infiltrated along the 7(th) and 8(th) nerve complexes into the internal auditory canal. CONCLUSION: Imaging and surgery disclosed a cerebello-pontine lymphoma with perineural extension along the 7(th) nerve to reach the middle cranial fossa. Because of the unusual imaging characteristics of this tumor, as well as special considerations with respect to treatment, preoperative consideration of this entity is important in planning direct surgical biopsy rather than an extensive resection.