Leukocytosis and C-Reactive Protein May Predict Development of Secondary Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage.

Background and Objectives: Secondary cerebral vasospasm (CV) with subsequent delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains an unpredictable pathology. The aim of this retrospective study was to investigate the association between inflammatory parameters, white blood cell (WBC) count, and C-reactive protein plasma levels (CRP) and the occurrence of secondary CV in patients with aSAH. Materials and Methods: The medical records of 201 Intensive Care Unit patients in Riga East University Hospital with aSAH were retrospectively reviewed in a 24-month period. WBC count and CRP values were observed at admission to the hospital and on the third day. According to the inclusion criteria, 117 (48 males) participants were enrolled for further analysis, with average age of 56 ± 15 years (mean ± SD). In total, secondary CV was diagnosed in 21.4% of cases, and DCI in 22.4% of cases. The patients were classified into three groups: SAH-CV group (n = 25), SAH-DCI group (n = 12), and SAH or control group (n = 80), for comparative analysis. Results: We found that SAH-CV patients demonstrated notably higher inflammatory parameters compared to controls: WBC 13.2 ± 3.3 × 109/L vs. 11.2 ± 3.7 × 109/L; p = 0.01 and CRP median 9.3 mg/L vs. 1.9 mg/L; p < 0.001, respectively. We found that the odds of developing CV increased by 5% for each CRP increase of 1 mg/L at admission (OR, 1.05; CI, 1.014-1.087; p = 0.006). Concomitantly, the odds increased by 16% for every rise in WBC count of 1 × 109/L (OR, 1.16; CI, 1.02-1.32; p = 0.02). WBC count was associated with the occurrence of CV with 96% sensitivity and 40% specificity, with a cut off level of 10.015 × 109/L and AUC 0.683; p = 0.006. CRP displayed 54% sensitivity and 90% specificity with a cut off value of 8.9 mg/L and AUC 0.751; p < 0.001. Moreover, higher values of inflammatory parameters at admission correlated with a longer stay in ICU (r = 0.3, p = 0.002 for WBC count and r = 0.305, p = 0.002 for CRP values), and poor outcome (death) was significantly associated with higher CRP values at admission and on the third day (16.1. vs. 2.2. and 57.4. vs. 11.1, p < 0.001, respectively). Higher mortality was detected in SAH-CV patients (32%) compared to controls (6.3%; p < 0.001). Conclusions: Inflammatory parameters such as WBC count and CRP values at admission might be helpful to predict the development of secondary CV.

Comparison between Diffusion-Weighted Sequences with Selective and Non-Selective Fat Suppression in the Evaluation of Crohn's Disease Activity: Are They Equally Useful?

Background: We compared the efficiency of two MRI diffusion weighted imaging (DWI) techniques: DWI with SPIR (DWISPIR) and DWI with STIR (DWISTIR), to estimate their eligibility for quantitative assessment of Crohn's disease activity in children and adults. Methods: In inflamed terminal ileum segments (n = 32 in adults, n = 46 in children), Magnetic Resonance Index of Activity (MaRIA) was calculated, ADC values of both DWI techniques were measured, and the corresponding Clermont scores calculated. ADC values of both DWI techniques were compared between both and within each patient group, assessing their mutual correlation. Correlations between MaRIA and the corresponding ADC values, and Clermont scores based on both DWI techniques were estimated. Results: No correlation between ADC of DWISPIR and DWISTIR was observed (rho = 0.27, p = 0.13 in adults, rho = 0.20, p = 0.17 in children). The correlation between MaRIA and Clermont scores was strong in both techniques-in SPIR, rho = 0.93; p < 0.0005 in adults, rho = 0.98, p < 0.0005 in children, and, in STIR, rho = 0.89; p < 0.0005 in adults, rho = 0.95, p < 0.0005 in children. The correlation between ADC and MaRIA was moderate negative for DWISTIR (rho = 0.93, p < 0.0005 in adults, rho = 0.95, p < 0.0005 in children), but, in DWISTIR, no correlation between ADC and MaRIA score was observed in adults (rho = -0.001, p = 0.99), whereas children presented low negative correlation (rho = -0.374, p = 0.01). Conclusions: DWISTIR is not suitable for quantitative assessment of Crohn's disease activity both in children and adult patients.

Musculomandibular morphology in individuals with different vertical skeletal growth patterns: an MRI and cone beam computed tomography study.

OBJECTIVE: The aim of this study was to analyse the volumetric and crossectional parameters of masseter and medial pterygoid muscles in the relation with mandibular skeletal morphology in individuals with different underlying growth patterns in the vertical dimension. MATERIAL AND METHODS: The study originally involved 76 individuals with definite clinical and radiological criteria: 31 skeletal Class III and 26 skeletal Class II patients before the orthognathic surgery and 20 skeletal class I (normal) individuals with complaints of wisdom teeth and associated medical problems. On the basis of cephalometric measurement of the mandibular plane and sella-nasion (MP-SN), the study sample was categorised according to the vertical facial dimension in 3 different growth pattern subgroups: 19 subjects with horizontal growth pattern, 25 subjects with vertical growth pattern and 33 subjects with neutral growth pattern. MRI was performed for the masseter and medial pterygoid muscles, and volume and cross-sectional area measurements were performed. Cone beam computed tomography (CBCT) investigation was performed for the assessment of craniofacial structures and the following measurements of the mandibular parameters were obtained: height of ramus, length of mandibular corpus, overall mandibular length, inter-angular width and intercondylar width. RESULTS: There were statistically significant differences among all study groups regarding masseter volume (p<0.006) and CSA (p<0.006), with the highest values in the horizontal growth pattern group and the lowest values in vertical growth pattern group. After Bonferroni correction, statistically significant difference (p<0.004 and p<0.008) was noted between the horizontal and vertical growth pattern groups, respectively. A similar tendency was observed for the medial pterygoid, but with no statistical significance. A statistically significant negative correlation was observed between MP-SN and the volume of masseter and medial pterygoid in the overall sample. Of the seven muscular and mandibular variables included in the regression analysis, the final model included only four variables that were significantly associated with MP-SN and explained 37% of its variance (masseter volume (p=0.017), mandibular overall length (p<0.001), height of mandibular ramus (p=0.003), and length of mandibular corpus (p<0.001)). CONCLUSIONS: The masseter muscle seems to be more sensitive to the variation in mandibular morphology than the medial pterygoid muscle, and volume as the biomechanical characteristic seems to be a more significant parameter of the size of the interaction with vertical skeletal growth patterns.

The Influence of Bowel Preparation on ADC Measurements: Comparison between Conventional DWI and DWIBS Sequences.

Background and objectives: The aim of the study was to assess whether there were differences between apparent diffusion coefficient (ADC) values of diffusion-weighted imaging (DWI) and diffusion-weighted imaging with background body signal suppression (DWIBS) sequences in non-prepared and prepared bowels before and after preparation with an enteric hyperosmolar agent, to assess whether ADC measurements have the potential to avoid bowel preparation and whether ADC-DWIBS has advantages over ADC-DWI. Materials and Methods: 106 adult patients without evidence of inflammatory bowel disease (IBD) underwent magnetic resonance (MR) enterography before and after bowel preparation. ADC-DWI and ADC-DWIBS values were measured in the intestinal and colonic walls demonstrating high signal intensity (SI) at DWI tracking images of b = 800 s/mm2 before and after preparation. Results: There were significant difference (p < 0.0001) in both ADC-DWI and ADC-DWIBS results between non-prepared and prepared jejunum for DWI being 1.09 × 10-3 mm2/s and 1.76 × 10-3 mm2/s, respectively, and for DWIBS being 0.91 × 10-3 mm2/s and 1.75 × 10-3 mm2/s, respectively. Both ADC-DWI and DWIBS also showed significant difference between non-prepared and prepared colon (p < 0.0001), with DWI values 1.41 × 10-3 mm2/s and 2.13 × 10-3 mm2/s, and DWIBS-1.01 × 10-3 mm2/s and 2.04 × 10-3 mm2/s, respectively. No significant difference between ADC-DWI and ADC-DWIBS was found in prepared jejunum (p = 0.84) and prepared colon (p = 0.58), whereas a significant difference was found in non-prepared jejunum and non-prepared colon (p = 0.0001 in both samples). Conclusions: ADC between DWI and DWIBS does not differ in prepared bowel walls but demonstrates a difference in non-prepared bowel. ADC in non-prepared bowel is lower than in prepared bowel and possible overlap with the ADC range of IBD is possible in non-prepared bowel. ADC-DWIBS has no advantage over ADC-DWI in regard to IBD assessment.

The relationship between mandibular rotation and osseous structure of the TMJ in pre-surgery orthognathic patients: A cone beam CT study.

The aim of the study was to assess the relationship between vertical skeletal pattern in terms of mandibular rotation and osseous structural changes of the TMJ in pre- surgical orthognatic patients. TMJ skeletal morphology was evaluated in cone beam computer tomography images of 117 consecutive patients with Class II and Class III dentofacial deformities according to the research diagnostic criteria of the osseous components of the TMJ related to the maxillary-mandibular plane (MM) angle. The distribution of the number and percentage of joints with structural changes in Class II was markedly different in groups divided according to the MM angle. Statistically significant increase was found in the percentage of TMJ's with osseous changes separately for each side, i.e., right (p=0.001), left (p=0.04) and both together (p=0.0001), in the Class II patient group, an increased MM angle indicated backward rotation of the mandible. In Class III patients, there were no statistically significant differences in the number of joints with TMJ structural changes. The presence of mentioned changes was asymmetrical between the left and right joints in both the Class II and Class III patient groups. In conclusion, structural changes in the osseous parts of the TMJ are more common in patients with Class II skeletal dentofacial deformities with backward rotation of the mandible than in Class III pre-surgery orthognathic patients.

Magnetic resonance study on fractional anisotropy and neuronal metabolite ratios in peritumoral area of cerebral gliomas.

BACKGROUND AND OBJECTIVE: Cerebral gliomas have a tendency to infiltrate the surrounding brain tissue for several centimeters from the core of tumor. The usefulness of structural magnetic resonance (MR) sequences is limited because of their insensitivity for the detection of tumor cells outside the visible tumor border. The aim of this study was to investigate the validity and the repeatability of 2 functional MR methods: fractional anisotropy (FA) and spectroscopy in the assessment of the peritumoral area of cerebral gliomas. MATERIAL AND METHODS: Forty-five patients with histologically verified brain gliomas underwent diffusion tensor imaging (DTI) and MR spectroscopy (MRS). Metabolic ratios were calculated from choline (Cho), creatine (Cr), N-acetylaspartate (NAA), lactate/lipids (LL), myo-inositol (MI) spectroscopic values obtained within the tumor center, perifocal edema, and distant and contralateral normal-appearing white matter. DTI maps of FA were calculated at the same locations. RESULTS: A significant gradual increase of FA and a decrease of LL/Cr ratios from the tumor center to the normal-appearing white matter were observed. The Cho/Cr ratio was significantly lower in the distant normal-appearing white matter than in the perifocal edema and the tumor center. The NAA/Cr ratio was significantly reduced in the tumor center, perifocal edema, and distant normal-appearing white matter compared with the contralateral hemisphere. MRS and DTI measurements of glioma and peritumoral area had a high degree of repeatability. CONCLUSIONS: Our study shows that MRS and DTI measurements are reproducible. The combined use of Cho/Cr, LL/Cr, and FA measurements is a promising MR technique that provides valuable additional information about the location of glioma potential border.

The value and limitations of contrast-enhanced ultrasound in detection of prostate cancer.

UNLABELLED: The aim of our study was to evaluate the diagnostic value of contrast-enhanced ultrasonography (CEUS) in comparision to morphological examinations of radical prostatectomy specimens and to study factors limiting the visibility of malignant lesions. PATIENTS AND METHODS: Fifty patients with proven prostate cancer (PV) were examined transrectally using, grey-scale, power Doppler (PD) and CEUS (pulse-inversion mode, low mechanical index) shortly before prostatectomy. The results were compared with morphological findings. The influence of tumour size, localization and grade on tumour visibility was studied. RESULTS: A total of 72 prostate cancer foci were found at pathologic evaluation. Grey-scale imaging demonstrated 34 (47.2%), power Doppler 37 (51.4%) and CEUS 44 (61.1%) of these foci. No lesion less than 1 cm in size was detected. Statistically significant correlation was established between the visibility of of tumour in CEUS and the size of a focus (r=0.610, p=0.001). Sensitivity of CEUS in detection of peripheral gland tumours was 63.3%, of lesions invading both peripheral and central gland 83.3%, and of centrally located tumours 27.8%. In comparision, sensitivity of grey-scale imaging was 53.3%, 70.8% and 5.6%, respectively. CEUS detected 35.5% of low-grade and 80% of intermediate-grade tumours; the corresponding results of grey-scale imaging were 16.1% and 70%, respectively. Statistically significant correlation was detected (r=0.459: p=0.001) between visualization capabilities of CEUS and the malignant grade of prostate cancer. CONCLUSION: CEUS improves prostate cancer detection. Sensitivity of CEUS is lower in cases of small low-grade tumours, centrally located lesions and large infiltrating prostate tumours.

Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of Class III malocclusion.

OBJECTIVE: The aim the study was to evaluate area and volumetric changes in the upper airway after bimaxillary correction of Class III malocclusion by the means of computer tomography (CT), and to compare these to the changes in linear measurements from lateral cephalograms. STUDY DESIGN: This was a prospective clinical trial. Lateral cephalograms and CT scans of 10 Class III patients were evaluated 1 week before and 6 months after surgery. Wilcoxon matched pairs signed ranks test was used to determine the differences in measurements pre- and postoperatively. Spearman's rank correlation was used to test the association between the CT and cephalometric measurements. RESULTS: CT measurements: The oropharyngeal and hypopharyngeal volumes increased by 3.98 +/- 4.18 cm(3) (P = .015) and 2.51 +/- 1.92 cm(3) (P = .021), respectively. The total volume of the posterior airway space increased, but the increase was not statistically significant. After surgery no change in the cross-sectional area of the upper airway was recorded at the retropalatal, oropharyngeal, or hypopharyngeal levels. Cephalometric measurements: The nasopharyngeal space increased 4.08 +/- 5.07 mm (P = .039) and the tongue increased in length by 4.84 +/- 5.93 mm (P = .22). No correlation was found between the measurements on CT scans and corresponding measurements on the lateral cephalograms. CONCLUSIONS: Bimaxillary surgery for correction of Class III malocclusion did not cause decrease of the posterior airway space. Three-dimensional imaging techniques are preferable to 2-dimensional lateral cephalograms for evaluation of the upper airway after orthognathic procedures.

Three-dimensional evaluation of musculoskeletal in Class II and Class III patients.

OBJECTIVE: To evaluate and compare dimensional morphology of masseter and medial pterygoid muscles and mandibular skeletal parameters between subjects with skeletal Class II and Class III. MATERIALS AND METHODS: The sample consisted of 13 patients with skeletal Class II and 10 patients with skeletal Class III prior to the start of combined orthodontic treatment and orthognathic surgery with correspondence to definite inclusion and exclusion criteria. Magnetic resonance imaging was performed for mandibular muscles and following 2D and 3D measurements were done: cross-sectional area (CSA), thickness, width, longitudinal dimension and volume. 3D multi-slice computed tomography investigation was performed for the assessment of skeletal mandibular parametres and following measurements were done: height of mandibular ramus, length af mandibular corpus, overall mandibular length, intergonial width. All the measurements were done bilaterally. Data were analyzed using descriptive statistics, t-test, and correlation coefficients. RESULTS: It was found that values of all mandibular and medial pterygoid measurements were higher in Class III subjects with statistical significance (p<0.05). There was a tendency of all masseter variables to be higher in Class III patients. Positive correlations were found between muscles' volume and CSA in both groups, muscles' volume and all mandibular parameters in Class II group, CSAs and all mandibular variables except intergonial width in Class II group. Overall symmetry was observed between left and right sides in all muscular and mandibular measurements in both groups. CONCLUSIONS: The data were acquired using two different imaging techniques - MRI and MSCT that can be mentioned as a novelty in this field of research. Remarkable differences were observed between study groups for both skeletal and muscular measurements.

Three-dimensional evaluation of TMJ parameters in Class II and Class III patients.

The aim of our study was to assess condylar parameters and condyle position within glenoid fossa of TMJ in volumetric 3D imaging in patients with Class II and Class III malocclusions. MATERIALS AND METHODS. The study group included 15 patients with severe skeletal Class II (mean age 18.0 yrs) and 14 patients with severe skeletal Class III ( mean age 19,2 yrs) with an indication for combined orthodontic and orthognathic treatment. CT examination was performed, pictures were reconstructed in three - dimensional (3D) rendering and measured in two dimension projection (2D) pictures using IAC review and Transparent bone programs to quantify following condylar and glenoid fossa parameters - glenoid fossa width and height; tuberculum articulare angle; anterior, superior and posterior joint space; height and width of condyle, height of procesus condylaris. Mean values were calculated separately for left and right side. Differences of the mean values were tested using paired t-test. RESULTS. There were statistically significant differences (p<0,05) between two study groups for all spatial measurements on both sides with larger spatial measurements in patients with Class II malocclusions. Also the height of procesus condylaris varied between groups with statistical difference. Unilateral differences were detected for width of fossa glenoidale and height of condyle. CONCLUSION. Results show that there are a tendency for smaller condyle and wider spaces between condyle and walls of glenoid fossa comparing TMJ of Class II with Class III patients.

Condylar and mandibular morphological criteria in the 2D and 3D MSCT imaging for patients with Class II division 1 subdivision malocclusion.

UNLABELLED: The condyle has a special multidirectional capacity for the growth and adaptive remodeling of temporomandibular joint (TMJ). Being part of TMJ structure, it plays an important role in the stability of long-term treatment results for orthodontic and orthognatic patients with Class II division 1 subdivision malocclusions. Several computed tomography (CT) investigation modes have been used to evaluate the craniofacial morphology and particularly, for TMJ. Dimensional images, acquired using new generation multislice CT (MSCT) and cone beam CT scanning data, are becoming increasingly popular in the clinical work and research. The aim of the study was to develop a new CT investigation protocol for the quantification of morphological structures and skeletal landmarks of condyle, procesus condylaris and mandible. For this purpose we created two dimensional (2D) and three dimensional (3D) reconstruction images from primary axial MSCT scans using IAC review and Transparent bone programms and acquired accordant measurements of condylar and mandibular structures. This technic allowed to get truly volumetric reflexion of the joint components in its real anatomical size and avoided the bony superimpositions. Our material included 12 patients with skeletal Class II division 1 subdivision malocclusion who had indications for combined orthodontic and orthognatic treatment. CT examination was performed before the start of treatment. For statistical analysis paired Student t-tests were applied to test the diferences of mean values and correlation coefficients were calculated to assess possible interrelations between measurements. The preliminary results showed weak corrrelation between condylar and mandibular measurements. More significant correlation was observed between procesus condylaris and mandible. It was a significant difference between right and left side in the height of procesus condylaris in patients without clinicaly relevant facial asymetry which could be considered in the individual planning of orthognatic treatment. CONCLUSION: The developed combined 2D and 3D MSCT investigation protocol for condylar and mandibular measurements provides precise and demonstrative quantitative images of condylar and mandibular structures and its dimensional relationships., which could be qualified as informative criteria for the individual treatment planning for patients with Class II division 1 subdivision malocclusion.

Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: results of a multicenter study.

RATIONALE AND OBJECTIVES: This cooperative multicenter human study was designed to evaluate the safety, magnetic resonance (MR) imaging characteristics, and clinical response to a single gadolinium contrast agent: gadopentetate dimeglumine. MATERIAL AND METHODS: Ninety-five patients (age range: 1 month to 78 years; sex: 50 males, 45 females) were included in this prospective study. The patients presented clinically with a variety of cranial or spinal signs and symptoms for which an intrathecal contrast myelogram or cisternogram was requested by clinical staff. Via lumbar puncture (20-25 g needle), 3 to 5 mL/ml of cerebrospinal fluid were withdrawn and mixed with a single volume of 0.5 (n = 63), 0.7 (n = 13), 0.8 (n = 12), or 1.0 (n = 7) cc/mL of gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany). This was then injected into the subarachnoid space, and the needle was removed. Immediate and delayed (up to 96 hours) T1- and T2-weighted MR imaging was performed on super conductive, high-field (1.0-1.5 tesla) imaging units in two or three planes. All patients were hospitalized for an observation period of 24 hours following the procedure, and follow-up neurologic examinations were performed serially for 6 to 12 months afterward. RESULTS: No patient manifested gross behavioral changes, neurologic alterations, or seizure activity at any time following the procedure. Nineteen patients (20%) experienced postural postlumbar puncture headache, six patients had nausea (6%), and two patients had episodes of vomiting (2%), all which resolved within the first 24 hours of the lumbar puncture with conservative bed rest. CONCLUSION: This cooperative study demonstrates the general safety and feasibility of low dose (0.5-1.0 mL/ml) intrathecal gadopentetate dimeglumine administration. The potential useful clinical applications include the evaluation of obstructions and communications of the various subarachnoid spaces, spontaneous or traumatic/postsurgical craniospinal cerebrospinal fluid leaks, and subarachnoid space CSF flow and parenchymal CNS interstitial diffusion dynamics. This worldwide cooperative study seeks to progressively perform human studies for further definitive evaluation of the practical clinical applications, of the relationship of this technique to other imaging studies and modalities, and the long-term safety of the procedure in a larger number of subjects.

Intrathecal gadolinium-enhanced MR cisternography in the evaluation of clinically suspected cerebrospinal fluid rhinorrhea in humans: early experience.

In this prospective multicenter study, the authors evaluated the utility of magnetic resonance (MR) cisternography after intrathecal administration of gadopentetate dimeglumine in 15 patients clinically suspected of having cerebrospinal fluid (CSF) rhinorrhea. By means of lumbar puncture, a single dose of 0.5 mL of gadopentetate dimeglumine was injected into the lumbar subarachnoid space. Thirteen patients showed leakage of contrast material through the cribriform plate into the ethmoid or sphenoid air cells. No leakage was observed in two patients. The study results show the relative safety and feasibility of low-dose gadolinium-enhanced MR cisternography in confirming the presence and determining the focus of active CSF leaks.