Whole-body computed tomography as first-line imaging procedure to exclude cancer in patients with neurological suspicion of paraneoplastic syndromes: shall clinical practice adhere to recommendations?

INTRODUCTION: To assess the efficacy of whole-body computed tomography (WB-CT) as imaging procedure to exclude cancer in patients with neurological symptoms and signs at clinical onset. METHODS: A retrospective observational study was designed to identify consecutive WB-CT requested by the Neurology Unit with a suspicion of an underlying tumor potentially linked to a paraneoplastic neurological syndrome (PNS) between January 2019 and February 2022. The following data were collected: diagnosis at admission and at discharge, the presence of onconeural antibodies, the scans dose length product (DLP), the estimated effective dose (ED), the total estimated time requested; the PNS-Care-Score was retrospectively calculated only in subjects with available antibodies. RESULTS: The total number of patients included was 158. In 13/158 (positive group) a malignant or locally aggressive neoplasm was found while in 145/158 no malignant lesions were found on the WB-CT. Among the positive group, in 7/13 onconeural antibodies were diagnosed, resulting negative in all cases and the most frequent tumor was lung cancer (30.8%). PNS-Care-Score was of 6-7 in 2/7 (probable PNS) and in no case the PNS-Care-Score was ≥8 (definite PNS). The mean DLP for all the scans was 2798 ± 952 mGy cm (average estimated ED of 42 ± 14 mSv). The total estimated time requested for all scans was 11,060 min. CONCLUSION: If a PNS is suspected, we encourage the prescription of unenhanced chest CT and/or abdomen/testis/female pelvis ultrasound and/or mammography based on clinical picture. The WB-CT using a single portal phase would be appropriate as a second-line technique while magnetic resonance imaging might be indicated for the exclusion of nervous system diseases. IMPLICATIONS FOR PRACTICE: Our suggestion results in saving in terms of radiation exposure, financial resources and time.

Inward versus reward: white matter pathways in extraversion.

The trait of extraversion is one of the longest-standing domains that captures the social dimension of personality and can potentially explain the covariation of a wide variety of behaviors. To date, there is a growing recognition that human behavior should be specified not only through the psychological mechanisms underlying each trait but also through their underlying neurobehavioral systems. While imaging studies have revealed important initial insights into the structural and functional neural correlates of extraversion, current knowledge about the relationships between extraversion and brain structures is still rather limited, especially with regard to the relationship between extraversion and white matter (WM). In this study, we aimed to investigate WM microstructure in extraversion in greater depth. Thirty-five healthy volunteers (21 women; mean age 35) underwent magnetic resonance imaging, as a part of a larger project aimed at investigating the longitudinal effect of motor training. WM integrity was assessed using the diffusion tensor imaging technique combining multiple diffusion tensor measures. Extraversion was assessed by the Eysenck Personality Questionnaire-Revised. Voxelwise correlation analyses between fractional anisotropy, axial diffusivities, and radial diffusivities maps and extraversion score showed decreased connectivity in the right inferior fronto-occipital fasciculus and forceps major among individuals who had high extraversion ratings. In conclusion, individual differences in extraversion may reflect differential organization of the WM tracts connecting frontal cortex, temporal, and occipital areas, which are related to socioemotional and control functions.

Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.

A reddish pulsatile mass beyond tympanic membrane: think before act.

We report a case of a 76-year-old man that referred to our hospital because of progressive mixed right hearing loss, aural fullness and pulsatile tinnitus synchronized with heart beats. Otoscopic examination revealed a reddish pulsatile mass beyond tympanic membrane. CT and MRI scans showed a class C glomus tumor. Anamnesis and a complete physical examination, with careful differential diagnosis, should be obtained to rule out highly vascularized middle ear lesion before any invasive procedure.

Interventional Radiologist's perspective on the management of bone metastatic disease.

Bone metastases can be treated by interventional radiologists with a minimally invasive approach. Such treatments are performed percutaneously under radiological imaging guidance. Different interventional techniques can be applied with curative or palliative intent depending on lesions and patients' status. In the whole, available interventional techniques are distinguished into "ablative" and "consolidative". Ablative techniques achieve bone tumor necrosis by dramatically increasing or decreasing intra-tumoral temperature. This option can be performed in order to alleviate pain or to eradicate the lesion. On the other hand, consolidative techniques aim at obtaining bone defect reinforcement mainly to alleviate pain and prevent pathological fractures. We herein present evidence supporting the application of each different interventional technique, as well as common strategies followed by interventional radiologists while approaching bone metastases.

Lumbar subcutaneous edema and degenerative spinal disease in patients with low back pain: a retrospective MRI study.

PURPOSE: This study was designed to determine the association between LSE, spondylolisthesis, facet arthropathy, lumbar canal stenosis, BMI, radiculopathy and bone marrow edema at conventional lumbar spine MR imaging. METHODS: This is a retrospective radiological study; 441 consecutive patients with low back pain (224 men and 217 women; mean age 57.3 years; mean BMI 26) underwent conventional lumbar MRI using a 1.5-T magnet (Avanto, Siemens). Lumbar MR images were reviewed by consensus for the presence of LSE, spondylolisthesis, facet arthropathy, lumbar canal stenosis, radiculopathy and bone marrow edema. Descriptive statistics and association studies were conducted using STATA software 11.0. Association studies have been performed using linear univariate regression analysis and multivariate regression analysis, considering LSE as response variable. RESULTS: The overall prevalence of LSE was 40%; spondylolisthesis (p = 0.01), facet arthropathy (p < 0.001), BMI (p = 0.008) and lumbar canal stenosis (p < 0.001) were included in the multivariate regression model, whereas bone marrow edema, radiculopathy and age were not. CONCLUSIONS: LSE is highly associated with spondylolisthesis, facet arthropathy and BMI, suggesting underestimation of its clinical impact as an integral component in chronic lumbar back pain. Longitudinal simultaneous X-ray/MRI studies should be conducted to test the relationship of LSE with lumbar spinal instability and low back pain.

Perilimphatic fistula test: a video clip demonstration.

Perilymphatic fistula (PLF) is an abnormal condition in which a communication is present between the perilymphatic space of the inner ear and the middle ear or mastoid, secondary to a dehiscence in the otic capsule, oval or round window. LF may induce hearing loss, tinnitus, aural fullness, vertigo, disequilibrium, or a combination of these symptoms; the vagueness of symptoms caused by PLF and the lack of specificity of clinical signs and symptoms make the diagnosis elusive. We report a video of a positive PLF test induced by the application of pressure on the tragus, just anterior to the left external auditory canal in a patient with cholesteatoma and PLF of lateral semicircular canal confirmed by CT scan imaging. https://www.youtube.com/watch?v=x5MhSILF9O4.

Acceleration of SLE-like syndrome development in NZBxNZW F1 mice by beta-glucan.

Beta-glucans are naturally occurring polysaccharides that exert important immunostimulatory activities. In the present study, we evaluated whether beta-glucans could modulate the development and the course of systemic lupus erythematosus (SLE). To this aim, we employed the classical model of SLE represented by the F1 hybrid between the NZB and NZW mouse strains which develop severe lupus-like phenotypes comparable to that of SLE patients. The administration of beta-glucan was associated to a more aggressive development of the disease and a worse prognosis, as observed from the clinical, biochemical and histopathological data. This finding implies that restraint should be practised in the possible use of beta-glucans as immunomodulators in human therapy in the context of SLE.

Identificación de papilomavirus humanos en lesiones cutáneas benignas y malignas no melanoma por métodos moleculares / Identification of human papillomavirus in benign and malignant nonmelanoma skin lesions by molecular methods

Los virus papiloma humano (PVH) están presentes en la piel como flora normal, donde permanecen en forma latente, pudiendo desarrollar en ciertas oportunidades, lesiones cutáneas. OBJETIVO: Identificar los tipos de PVH con tropismo por epitelios cutáneos y analizar su posible asociación con lesiones cutáneas benignas y carcinomas cutáneos no melanoma. MATERIALES Y MÉTODOS: Estudio prospectivo realizado en el servicio de dermatología del Hospital provincial del Centenario, desde Junio de 2007 a Noviembre de 2008. Se obtuvieron muestras mediante hisopados de regiones: fotoexpuesta (FE), no fotoexpuesta (NFE), perilesional (PL), superficie de lesión (SL) y biopsias de lesiones para estudio histopatológico. Se incluyeron pacientes derivados para estudio histopatológico de las lesiones antesreferidas. Detección de PVH mediante PCR. RESULTADOS: Participaron 67 pacientes, 41 hombres y 26 mujeres, edad promedio de 51 años (rango: 19-89 años). 300 muestras resultaron idóneas para la amplificación por PCR. La frecuencia de ADN de PVH hallado fue del 58% (176/300) (Figura 1), encontrándose 75% en FE, 39% en NFE, 75%en PL, 66% en SL y 35% en las biopsias. Se identificaron 69 tipos diferentes de HPV, siendo más frecuentes el 2, 21, 20 y 6. Se detectó un nuevo PVH,el 115. No se identificó PVH en muestras de carcinomas. En queratosis seborreicas se detectó en un 27%. CONCLUSIONES: Se obtuvieron datos acerca de los PVH circulantes en los pacientes de nuestra región. Corroboramos la influencia de la radiación ultravioleta sobre la infección por este virus, así como su presencia en queratosis seborreicas. Identificamos un nuevo HPV en Sudamérica

The human papillomavirus (HPV) establish a latent infection of the skin as normal flora and can develop skin lesions on some situations. OBJECTIVES: Identify the HPV types which exhibit tropism for cutaneous epithelium and analyse its possible association with benign skin lesions and nonmelanoma skin cancer. MATERIALS AND METHODS: Prospective study was carried out in the Department of Dermatology at the Centenario Provincial Hospital from June 2007to November 2008. Samples were collected by swabs from the following areas: sun-exposed (FE), non-sun-exposed (NFE), perilesional (PL), lesion area(SL) and biopsy of lesions for histopathological study. We included patients referred to surgical removal of a skin lesion for histopathological study. Detection of HPV by PCR.RESULTS:67 patients were recruited, 41 men and 26 women, median age of 51 years (range, 19-89 years). 300 samples were suitable for amplification by PCR. HPV DNA was present in 58% of the analyzed samples (176/300), and 75% in FE, 39% in NFE, 75% in PL, 66% in SL and 35% in biopsies. 69 different types of HPV were identified, being more frequent 2, 21, 20, and 6. We detected a new HPV, 115. HPV were not identified in samples of car-cinomas. In seborrhoeic keratosis were present in 27% of the samples.CONCLUSIONS:We collected data about the HPV circulating in patients of our region. We affirmed the influence of ultraviolet radiation on this viralinfection, as well as their presence in seborrhoeic keratosis. We identified a new HPV in South America

Dynamic contrast-enhanced MR evaluation of prostate cancer before and after endorectal high-intensity focused ultrasound.

PURPOSE: The authors sought to determine the diagnostic performance of dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging in the evaluation of prostate cancer before and after transrectal high-intensity focused ultrasound (HIFU) treatment. MATERIALS AND METHODS: We analysed 25 patients with prostate cancer. The prostate-specific antigen (PSA) value was evaluated 1, 4 and 6 months after treatment. DCE-MR imaging was performed the day prior to and 1, 4 and 6 months after HIFU treatment. Transrectal prostate biopsies were obtained at the time of diagnosis and 6 months after treatment. RESULTS: Before treatment, intraglandular lesions were considered to be potential sites of neoplasm and subsequently confirmed as sites of prostate adenocarcinoma in all 25 patients based on prostatespecific antigen (PSA) values and histological examinations (rho=1; p<0.001). Using histology as the gold standard, DCE-MR imaging displayed 100% sensitivity, 100% specificity, 100% positive predictive value and 100% negative predictive value before treatment. After HIFU treatment, DCE-MR imaging showed 100% sensitivity and 96% specificity. CONCLUSIONS: DCE-MR imaging can be used to visualise prostate adenocarcinoma. Several morphological and postgadolinium modifications in the follow-up DCE-MR images after HIFU treatment were also observed.

Upper airway study should always come before any sleep study in OSAS evaluation: a giant parapharyngeal lipoma behind OSAS.

BACKGROUND: The parapharyngeal space (PPS) is a rare site for neoplasms in the head and neck and lipoma represents 0.5% of all head and neck tumors. CASE REPORT: We describe a case of a giant parapharyngeal lipoma in obese adult patient causing anatomic pharyngeal obstruction with severe obstructive sleep apnea (OSA) syndrome. The patient was successfully operated with transcervical approach. CONCLUSIONS: In patients presenting with symptoms suggestive of OSA, it is essential to rule out any physical cause and perform a comprehensive ear, nose and throat examination including fibro-endoscopic upper airway examination before referral for sleep study and management. The ideal management for OSA involves treating the underlying cause. If no definitive cause is identified, management should begin with conservative measures such as lifestyle changes and a weight loss program; if these are unsuccessful, continuous positive airway pressure (CPAP), oral appliances or upper airway surgery could be considered. Better diagnostic methods should be developed to identify the main OSA causes and improve therapeutic outcomes.

Meningeal involvement in Wegener granulomatosis: case report and review of the literature.

Wegener Granulomatosis (WG) is a multisystem autoimmune disorder characterized by necrotizing granulomatous vasculitis that most commonly involves the upper respiratory tract, lungs, and kidneys. The involvement of the central nervous system (CNS) is infrequent and can cause stroke, cranial nerve abnormalities, cerebrovascular events, seizures, and meningeal involvement. Meningeal involvement is rare and may occur due to local vasculitis, directly spread from adjacent disease in the skull base, paranasal or orbital region. We describe the case of a 20-year-old Caucasian man who was diagnosed with sinonasal WG with frontal focal meningeal involvement. A literature review on diagnosis and treatment of meningeal involvement in course of WG was carried out. The importance of an early diagnosis and treatment of localized WG has been emphasized, in order to avoid the progression to a severe form of disease, especially in younger patients and in paucisymptomatic cases.

Central nervous system tuberculosis in non-HIV-positive children: a single-center, 6 year experience.

PURPOSE: The aim of this paper is to describe the imaging features of central nervous system (CNS) tuberculosis on computed tomography (CT) and magnetic resonance imaging (MRI) studies in non-HIV-positive children. MATERIALS AND METHODS: A retrospective descriptive evaluation was conducted on imaging studies obtained from ten children admitted to our hospital over a 6-year period who fulfilled criteria for a diagnosis of CNS tuberculosis. Data were collected with regard to patients' clinical, laboratory and demographic characteristics, as well as results of radiological investigation. RESULTS: We studied ten children, of whom five were boys and five were girls and whose mean age was 4 (range 7 months to 16) years. Neuroradiological findings on the first imaging study were basal meningeal enhancement (100%), hydrocephalus (70%), infarcts (90%), tuberculomas (40%) and cranial nerve involvement (20%). Follow-up studies revealed basal meningeal enhancement, hydrocephalus, and infarcts in all patients, tuberculomas in 70% and cranial nerve involvement in 50%. Only one patient showed a pattern of miliary tuberculosis. CONCLUSIONS: CNS tuberculosis is still an important cause of childhood morbidity and mortality even in nonimmunosuppressed children. Because prompt diagnosis results in earlier treatment, it is crucial to be aware of tuberculous meningitis and its complications at imaging, especially because of the impact on patients' prognosis.

Prevention of clinical and histological signs of proteolipid protein (PLP)-induced experimental allergic encephalomyelitis (EAE) in mice by the water-soluble carbon monoxide-releasing molecule (CORM)-A1.

We have evaluated the effects of the carbon monoxide-releasing molecule CORM-A1 [Na(2) (BH(3) CO(2) ); ALF421] on the development of relapsing-remitting experimental allergic encephalomyelitis (EAE) in SJL mice, an established model of multiple sclerosis (MS). The data show that the prolonged prophylactic administration of CORM-A1 improves the clinical and histopathological signs of EAE, as shown by a reduced cumulative score, shorter duration and a lower cumulative incidence of the disease as well as milder inflammatory infiltrations of the spinal cords. This study suggests that the use of CORM-A1 might represent a novel therapeutic strategy for the treatment of multiple sclerosis.

Modic changes: anatomy, pathophysiology and clinical correlation.

Studying discovertebral complex anatomy is extremely important for the understanding of the pathophysiology of disc degeneration which leads to vertebral endplates signal changes, also known as Modic changes.The sequelae of disc degeneration are among the leading causes of functional incapacity in both sexes and are one of the most common sources of chronic disability in the working years. Even if the presence of degenerative changes in MRI of the spine is by no means an indicator of symptoms, we are concordant in a positive association between Modic changes and low back pain, above all as a relatively specific but insensitive sign of discogenic low back pain.

Specific and strain-independent effects of dexamethasone in the prevention and treatment of experimental autoimmune encephalomyelitis in rodents.

Experimental autoimmune encephalomyelitis in rodents (EAE) is a generally accepted in vivo model for immunopathogenic mechanisms underlying multiple sclerosis (MS). There are, however, different forms of rodent EAE, and therapeutic regimens may affect these forms differently. We have therefore tested the effects of dexamethasone (Dex) and found that both prophylactic and early therapeutic regimens were effective in suppressing the development of monophasic EAE in myelin basic protein-immunized Lewis rats, the relapsing-remitting forms of EAE induced in SJL mice by proteolipid protein and in DA rats by syngeneic spinal cord homogenate, and the progressive forms induced in C57BL/6 and DBA/1 mice by immunization with myelin oligodendrocyte glycoprotein. In addition, prophylactically administered Dex suppressed histological and immunological features of EAE such as spinal cord infiltration of inflammatory cells and the increased frequency of autoantigen-specific interferon-gamma-secreting lymph node mononuclear cells. The present data reproduced in rodent EAE models some of the beneficial effects observed with glucocorticoids in MS. This strengthens the validity of these five models as in vivo predictors of drug efficacy in at least some variants of human MS. Better understanding of the clinical and immunopharmacologic features of these models might prove useful when testing new drug candidates for MS treatment.

Differentiation of normal and neoplastic bone tissue in dynamic gadolinium-enhanced magnetic resonance imaging: validation of a semiautomated technique.

PURPOSE: This study was undertaken to clinically validate the accuracy of a semiautomated software tool for analysing the enhancement curve in focal malignant bone lesions. MATERIALS AND METHODS: Twenty-three patients affected by cancer with malignant focal bone lesions underwent dynamic gadolinium-enhanced magnetic resonance (MR) imaging using the following protocol: T1-weighted turbo spin-echo sequences (time to repeat [TR] 600 ms, time to echo [TE] 8.6 ms, field of view [FOV] 40x40 cm) before and after intravenous injection of gadolinium-containing contrast agent. Image postprocessing was performed using the software DyCoH. Each region of interest (5x5 pixels), drawn to include the area of the lesion with the highest values of the area under the curve map, was analysed to obtain time-intensity curves and relative perfusion parameters: time to peak (TTP), peak intensity (PI), slope (60-s slope), intensity at 60 s after contrast agent injection (60-s I) and final intensity (FI). RESULTS: Data were obtained by analysing 86 malignant lesions and 86 apparently normal bone regions. PI, 60-s slope, 60-s I and FI were significantly different between neoplastic and apparently normal (p<0.001) samples. Sensitivity, specificity and accuracy were, respectively, 94%, 93% and 94% at a PI threshold of 100 (signal-to-noise ratio), with positive and negative predictive values of 93% and 94%. At a threshold value of 0.85 for 60-s slope, sensitivity and specificity values were both 91%. CONCLUSIONS: The semiautomated technique we report appears to be accurate for identifying neoplastic tissue and for mapping perfusion parameters, with the added value of a consistent measurement of perfusion parameters on colour-coded maps.

Incidence of new fractures in women with osteoporosis-induced vertebral fractures detected on routine lateral chest radiographs.

PURPOSE: Vertebral fractures represent one of the major complications of osteopororis. Diagnosis is followed by a pharmacological, interventional or surgical treatment. Up to day there are non practice guidelines for a screening evaluation of bone fractures in elderly and most of the fractures remain undiagnosed. We prospectively evaluated the prevalence of vertebral fractures on chest X-rays to determine the diagnostic and prognostic roles of chest X-ray in predicting new bone fractures 2 years after the initial radiogram. MATERIALS AND METHODS: Between March 2004 and October 2005, 4,045 women underwent chest X-ray in our radiology department for any indication. We identified 166 women with the presence of at least one vertebral fracture. A questionnaire was administered to these women to collect information about diagnosis of osteoporosis, history of malignancy, systemic diseases, osteoporosis-inducing drugs and pharmacological, radiological or surgical treatment received. RESULTS: Out of the 166 women (age 73+/-10.5 years) with vertebral fractures, we interviewed 101 women; 13 had died and 52 were not found. Most of the patients were on menopause (97.1%, 98/101) with an average age of menopause of 48,2 years (+/-6 years). Among the patients on menopause, 15,8% (16/101) had undergone hysterectomy. All patients received a diagnosis of osteoporosis, which was reached with a chest X-ray report in 23.7% (24/101) of cases. A new skeletal fracture occurred in 20.5% (5/27) of patients receiving treatment against a frequency of 20.8% (16/74) in patients without treatment. No statistical difference was found between the groups (p = 0.374). CONCLUSIONS: Inadequate treatment may explain the lack of a substantial difference in new fracture risk between treated and untreated patients. For these reason we discuss about the evaluation of an adeguate therapeutic approaches in prevention of osteoporosis-induced fractures.