Clinico-radiologic profile of spinal cord multiple sclerosis in adults.

MRI is extremely useful for the assessment of initial disease burden and to identify the dissemination of the multiple sclerosis (MS) in time and space. Though MRI of the spinal cord is not used to establish the diagnosis of MS, spinal cord is frequently involved in this disease and there has been increasing emphasis of the spinal imaging in making clinical decision in the management of MS. We undertook a retrospective study of patients with diagnosed MS: 1) to identify radiologic pattern of spinal cord involvement in MS and 2) to correlate radiologic findings with clinical presentation. We reviewed radiologic records from 2004 to 2009 of patients with abnormal T2 signal intensity of the spinal cord with radiologic concern of demyelinating disease. Patients in this cohort who met the Revised McDonald MS Diagnostic Criteria were included in this study. 166 patients were included in the study. There was preference for cervical spinal cord particularly posterior aspect of the spinal cord. Enhancement of the lesions was rare (4.1%). Mean lesion length was 18.2 mm. The average number of lesions per patient was 2.04. Sensory symptoms were predominating and most of the patients had relapsing-remitting course. Patients with sensory symptoms, bladder and bowel involvement and motor symptoms had almost equally distributed lesions among anterior, posterior and central spinal cord. However, all of the patients presented with posterior column signs and gait abnormality had involvement of the posterior spinal cord. Radiologic manifestation of spinal cord MS is extremely variable and can involve the entire length of the spinal cord. Clinical symptoms may or may not be associated with radiologic presentation of the lesions.

JC virus infection of the brain.

Since its initial description, there have been significant changes in the epidemiology, pathogenesis, and clinical and imaging manifestations of JCV infection of brain. The most common clinical manifestation is PML. Other recently described CNS manifestations are JCE, JCVGCN, and JCM. Although AIDS is the most common predisposing factor for JCV reactivation, there is increasing incidence of brain manifestations of JCV reactivation in non-HIV settings, including different rheumatologic, hematologic, and oncologic conditions; monoclonal antibody therapy; transplant recipients; primary immunodeficiency syndromes; and even in patients without any recognizable immune deficiency. IRIS may develop secondary to restoration of immunity in HIV-positive patients with PML receiving antiretroviral therapy. This is of profound clinical significance and needs to be diagnosed promptly. Imaging plays a crucial role in the diagnosis of the disease, monitoring of treatment response, identifying disease progression, and predicting prognosis. In this article, current understanding of the epidemiology, pathogenesis, clinical presentations, and all aspects of imaging of JCV infection of the brain have been comprehensively reviewed.

Correlation of MR imaging findings and clinical manifestations in neurosarcoidosis.

BACKGROUND AND PURPOSE: MR imaging is widely used for the diagnosis and follow-up of neurosarcoidosis lesions. However, the temporal evolution of imaging abnormalities and the prognostic significance of imaging features is not well understood. We undertook a retrospective study of patients with biopsy-proved or clinically diagnosed neurosarcoidosis for the following reasons: 1) to assess concordance between abnormalities noted on MR imaging with neurologic symptoms at presentation; 2) to correlate changes in imaging findings during follow-up with clinical improvement or worsening; and 3) to identify imaging features that may have prognostic significance. MATERIALS AND METHODS: We reviewed radiologic records from 1999 to 2008 of patients with biopsy-proved or clinically diagnosed neurosarcoidosis and correlated MR imaging findings in these patients with their demographic characteristics, clinical features, and symptomatic responses during follow-up. RESULTS: Thirty-two patients were included in the study. Cranial nerve lesions and leptomeningeal disease identified on MR imaging were symptomatic in 64% patients, dural lesions were associated with symptoms in 28% patients, but nonenhancing white matter lesions did not have correlating symptoms. During follow-up, MR imaging findings generally changed in concordance with the change in clinical symptoms (80% patients). Cranial nerve enhancement (9/11) and spinal lesions (5/8) were most likely to resolve with clinical improvement, whereas dural lesions (6/11), enhancing parenchymal lesions (3/7), and non-enhancing parenchymal lesions (0/4) were less likely to change during therapy. Patients with > or =1 enhancing T2-hypointense lesion (4/7, 57%) were less likely to show clinical improvement than those without such lesions (12/13, 92%). CONCLUSIONS: Although many sarcoid-related MR imaging abnormalities were not associated with correlating symptoms at presentation, there was a high degree of concordance between changes in clinical symptoms and MR imaging abnormalities during follow-up. Enhancing T2-hypointense dural and parenchymal lesions were associated with suboptimal imaging and clinical response to immunosuppressive therapy.

Spontaneous resolution of cavum veli interpositi. A case report and review of the literature.

Cavum veli interpositi is an open CSF space in the roof of the third ventricle that surrounds the internal cerebral veins, and is a forward extension of the quadrigeminal plate cistern. To the best of our knowledge, spontaneous resolution of a cavum veli interpositi has not been reported in the literature to date. Interestingly, case reports of spontaneous resolution of cystic cavum septum pellucidum in three patients and eighteen arachnoid cyst cases has been described in the literature. We describe the spontaneous resolution of a cavum veli interpositi or cyst in cavum veli interpositi in a 35-year-old man and review the literature of spontaneous resolution of cavum septum pellucidum and arachnoid cysts.

Integrated radiology information system, picture archiving and communications system, and teleradiology--workflow-driven and future-proof.

The proliferation of integrated radiology information system/picture archiving and communication system (RIS/PACS) and teleradiology has been slow because of two concerns: usability and economic return. A major dissatisfaction on the usability issue is that contemporary systems are not intelligent enough to support the logical workflow of radiologists. We propose to better understand the algorithms underlying the radiologists' reading process, and then embed this intelligence into the software program so that radiologists can interact with the system with less conscious effort. Regarding economic return issues, people are looking for insurance against obsolescence in order to protect their investments. We propose to future-proof a system by sticking to the following principles: compliance to industry standards, commercial off-the-shelf (COTS) components, and modularity. An integrated RIS/PACS and teleradiology system designed to be workflow-driven and future-proof is being developed at Texas Tech University Health Sciences Center.

Radiology information systems, picture archiving and communication systems, teleradiology--overview and design criteria.

Information technology (IT), long taken for granted in commercial settings, is now being utilized for health-care applications. Medical imaging has lagged comparatively due to the extremely vast data content of each frame; thus, the requirement for expensive high-end components. Further, IT in radiology has evolved from two distinctly separate camps--information systems, known as RIS (radiology information systems) and PACS (picture archiving and communications systems). Both RIS and PACS applications have migrated to the PC environment, enabling cost-effective implementation, but from two backgrounds: RIS from vendors using conventional information systems platforms and products, and PACS from radiographic film and modality vendors. The radiology department at Texas Tech University has assembled a seamlessly integrated, enterprise-wide RIS/PACS/teleradiology intranet. The design criteria include user-friendliness, flexibility to respond to changing needs, and open modular architecture to assure interoperability, cost-effectiveness, and future-proofing of investment. Since no single venor could provide an integrated system meeting our specifications, we decided to assume the burden of constructing our own system. As the system integrator, we embrace open architecture, thus enabling the incorporation of industry-standard-compliant, COTS (commercially off the shelf) products as modules. Microsoft Windows NT operating system, Visual C++ programming language, TCP/IP (transmission control protocol/internetworking protocol), relational SQL (structured query language) database, ODBC (open database connectivity), HL-7 (health level seven) and DICOM (digital imaging and communications in medicine) interfaces are utilized. The usage of COTS components reduces the cost to very affordable levels. With this approach, any module in our system can be replaced when outmoded, without affecting other modules in our system, making it truly future-proof. Construction and evolution of our system (TECHRAD) is reviewed.

Secondary syringomyelia due to intramedullary spinal cord metastasis. Case report and review of literature.

Intramedullary spinal cord metastasis is relatively rare. We describe a patient having intramedullary spinal cord metastasis associated with syringomyelia, confirmed by magnetic resonance imaging, in a patient who had poorly differentiated carcinoma of the lung. The patient responded to treatment with steroids and radiotherapy, with complete resolution of neurologic symptoms and syringomyelia.

Progressive thrombosis after treatment of diffuse large cell non-Hodgkin's lymphoma and concomitant lupus anticoagulant.

We report a case of diffuse large cell non-Hodgkin's lymphoma with concomitant lupus anticoagulant at initial diagnosis. Progressive thrombosis occurred despite radiologically proven response of the lymphoma after chemotherapy treatment. Extraordinary bone scintigraphy with multiple "cold" lesions probably due to bone ischemia is described.

Angiographic appearance of carotid occlusion in acute stroke.

The angiographic appearance of the proximal end of internal carotid artery occlusion is reported in 41 patients with acute stroke in the areas of the brain supplied by the carotid artery. All patients had angiography within 6 days of stroke onset, the majority within 24--48 hours. Three angiographic configurations of internal carotid occlusion were found, in descending order of frequency: a sharp, pointed stump; virtual absence of the artery; and a rounded, blunt stump. The results suggest that the angiographic appearance of the proximal occlusion alone may not accurately predict the age of the occlusion within the first 6 days from stroke onset.

Radiological aspects of inverted papilloma.

Of 115 proved cases of inverted papilloma, 81 were studied radiographically. The tumor was seen in both early and late stages. Many cases presented as recurrent tumor after multiple surgical procedures. A common radiologic presentation was a unilateral mass in the nasal fossa with opacification of the contiguous maxillary sinus in a moderately advanced tumor stage. However, other radiologic patterns were encountered and it was therefore impossible to categorize any of these findings as specific for inverted papilloma.

Evaluation of mucoceles of the paranasal sinuses with computed tomography.

Eighteen patients with mucoceles of the paranasal sinuses were studied by plain radiography, pluridirectional tomography, and computed tomography (CT). Sixteen of the lesions had a homogeneous appearance on CT but demonstrated variable absorption characteristics, with acutely infected mucoceles showing rim enhancement. Plain radiography and pluridirectional tomography were usually sufficient for making a diagnosis and defining the extent of the lesion, but CT more accurately demonstrated orbital and intracranial extension. Both transverse and coronal CT are essential for adequate evaluation.

Therapeutic embolization of juvenile angiofibroma.

Therapeutic embolization of juvenile angiofibromas was performed in 15 boys, aged 12--18 years, 11 of whom subsequently underwent surgery. Intraoperative blood loss was reduced from an average of 2,400 ml in nonembolized patients to 800 ml after embolization. Angiography is of value to confirm the diagnosis prior to excision and to delineate the extent of the tumor. Embolization may be performed at the same sitting as a presurgical adjunct or possibly as a definitive or palliative therapeutic method. The embolization procedure is discussed in detail, emphasizing techniques and potential hazards of such procedures.

Mechanisms of acute carotid stroke.

In a three-year study, the clinical course and results of intracranial angiography were compared in patients having an acute stroke in the carotid artery territory combined with angiographic abnormalities indicating severe extracranial carotid stenosis or occlusion. Two major mechanisms of stroke were delineated. In one group, the angiographic intracranial abnormalities strongly suggested the presence of embolism in the cerebral vessels supplied by the stenotic or occluded carotid artery; many of these patients had no obvious transient ischemic attacks prior to their stroke and experienced a moderate to severe clinical deficit. In the other group, evidence of embolism was absent; many showed a widespread delay in cerebral arterial perfusion, experienced a greater frequency of transient ischemic attacks before their stroke, and had a milder stroke than did those with embolism.

Angiography and embolization of the internal maxillary artery for posterior epistaxis.

Epistaxis that originates from the posterior aspect of the nasal cavity is most often due to hemorrhage from one of the branches of the internal maxillary artery. There are multiple methods of treatment of this problem that vary in effectiveness, complexity, and stress on the patient. Most cases are controlled with either packing or surgical arterial ligation, but occasionally patients either cannot tolerate this therapy or continue to hemorrhage. We describe ten patients who were referred to the Neuroradiology Section of the Massachusetts General Hospital from the Massachusetts Eye and Ear Infirmary for angiography and embolization of the internal maxillary artery for epistaxis.

Computed tomography of masses in the lacrimal gland region.

Twenty patients with mass lesions in the lacrimal gland region were evaluated with computed tomography (CT). The extent of the mass and its relationship to the globe, optic nerve, and extraocular muscles were clearly seen. The CT appearance on plain scan and the presence or absence of contrast enhancement, bone involvement, and cystic components often suggested the specific pathological diagnosis. Although orbital ultrasonography and CT were frequently complementary, ultrasonography was more definitive in inflammatory diseases, while CT demonstrated better extraorbital extension.