Utility of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome: importance of risk classification.

PURPOSE: To assess the diagnostic impact of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome (PNS) based on our own pre-test risk classification (PRC). METHODS: A multicenter retrospective longitudinal study was conducted from 2006 to 2014. We designed a seven-point scoring system using the clinical syndrome characteristics [classical (CS) and non-classical syndromes (NCS)] and its location (central, peripheral, in the neuromuscular junction or combined), onconeural antibodies and tumor markers. Patients were classified as low (score 0-2), intermediate (3-4) and high (5-7) pre-test risk of PNS. FDG-PET/CT was classified as negative or positive. Final diagnosis according Graus' criteria (definite, possible or no PNS) was established. Relations between clinical and metabolic variables with the final diagnosis were studied. RESULTS: 73 patients were included, with a follow-up time of 33 months. Eleven (15 %) patients were finally diagnosed with neoplasm (8 invasive cancers). Ultimately, 13 (18 %) and 24 (33 %) subjects were diagnosed as definite or possible PNS. All the patients with final diagnosis of neoplasm had a CS (p = 0.005). PET/CT was helpful to diagnose 6/8 (75 %) invasive cancers. PET/CT findings were associated with the final diagnosis of neoplasm (p = 0.003) and the diagnosis of PNS attending to Graus' criteria (p = 0.019). PRC showed significant association with the final diagnosis of neoplasm and PET/CT results. A majority of patients (10/11) diagnosed of neoplasm had intermediate/high-risk. CONCLUSIONS: Our PRC seems to be a valid tool to select candidates for PET/CT imaging in this setting. PET/CT detected malignancy in a significant proportion of patients with invasive cancer.

[(18)F-FDG PET/CT in the evaluation of patients suspected of paraneoplastic neurological syndrome]. / PET/TC con (18)F-FDG en la valoración de pacientes con sospecha de síndrome paraneoplásico neurológico.

OBJECTIVE: This study aimed to determine the diagnostic impact of (18)F-FDG PET/CT based on the clinical features of paraneoplastic neurological syndrome (PNS). MATERIAL AND METHODS: Multicenter retrospective and longitudinal study of patients with suspicion of PNS. The clinical picture was classified into classic (CS) and non-classic syndrome (NCS). After the follow-up, the definitive or possible diagnosis of PNS was established. The pictures that did not match any of the previous criteria were categorized as non-classifiable. The state of the onco-neural antibodies was studied. The PET/CT was classified as positive or negative for the detection of malignancy. The relationship between PET/CT findings and the final diagnosis was determined. The differences between variables (Pearson test X(2)) and the relationship between the results of the PET/CT and the final diagnosis were analyzed. RESULTS: A total of 64 patients were analyzed, classifying 30% as CS and 42% as NCS. After the follow-up, 20% and 16% of subjects were diagnosed as possible and definitive PNS, respectively. Positive onco-neural antibodies were found in 13% of the patients. A definitive diagnosis of PNS was associated with a positive PET/CT (P=.08). A significant relation between antibodies expression and final diagnosis of neoplasia (P=.04) was demonstrated. The PET/CT correctly localized malignancy in 5/7 cases of invasive cancer. CONCLUSIONS: The PET/CT showed a higher percentage of positive results in patients with definitive diagnosis of PNS. Despite the low prevalence of malignancy in our series, the PET/CT detected malignancy in a significant proportion of patients with invasive cancer.

Oftalmoplejía completa secundaria a un infarto talámico paramediano bilateral / Complete ophthalmoplegia secondary to a bilateral paramedian thalamic infarct

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Origen común de arterias carótidas y subclavias como variante anatómica excepcional del arco aórtico / Common origin of carotid and subclavian arteries as an exceptional anatomical variant of the aortic arch

No disponible

[Recurrent painful ophthalmoplegia secondary to polyostotic fibrous dysplasia of the maxillary sinuses with involvement of the superior orbital fissure]. / Oftalmoplejia dolorosa recurrente secundaria a displasia fibrosa poliostotica del seno maxilar con afectacion de la hendidura esfenoidal.

INTRODUCTION: Fibrous dysplasia is a bone disease that is usually accompanied by asymptomatic lesions but which may sometimes display neurological manifestations due to the involvement of the craniofacial bones. CASE REPORT: A 25-year-old female, with a history of migraines, who visited at the age of 18 due to pain in the right retro-ocular and maxillary region, although with characteristics that were unlike those of her usual migraines, and which was associated with ipsilateral ophthalmoparesis. The condition had a self-limiting course and responded well to corticoids, although it was recurring. Examination revealed intense pain on palpation of the right-hand maxillary sinus and incomplete paralysis of the ipsilateral oculomotor nerve with palpebral ptosis. Results of complementary studies were normal, except for magnetic resonance imaging of the head and computerised axial tomography of the face, which revealed an expansive lesion with involvement of the right superior maxillary sinus and the greater wing of the sphenoid bone, with probable compromise of the superior orbital fissure, consistent with the diagnosis of fibrous dysplasia, which was confirmed by means of a pathology study. CONCLUSIONS: Fibrous dysplasia is a benign bone disorder, of unknown causation, in which normal bone tissue is replaced by amorphous conjunctive tissue. There is sometimes craniofacial involvement and a hypertrophic bone mass is formed which can fill the paranasal sinuses and the orbit, resulting in exophthalmus and visual disorders. To date the scientific literature does not include any reports of this disease manifesting as bouts of recurrent painful ophthalmoparesis which responds to corticoids, as happened in the case of our patient.

[Impact of warning against procrastination of thrombolysis in ischemic stroke]. / Impacto de las advertencias contra la procrastinación sobre las demoras en la trombólisis del ictus.

INTRODUCTION: Fibrinolysis in stroke should be carried out as soon as possible, but delays occur for various reasons. In the first 17 ischemic infarcts treated in our center we confirmed a tendency to exhaust the therapeutic window. We look now at whether warnings against this tendency, without other logistical or organizational modifications, have had an impact on delays. PATIENTS AND METHODS: Neurologists were encouraged to avoid procrastination. When we reached 51 treated patients, we compared features and delay times between the first 17 (February, 2002 to June, 2004) and the 17 most recent cases (October, 2005 to April, 2006). Non-parametric tests were used (significant if p < 0.05). RESULTS: Both groups were similar clinically and demographically. The onset-arrival time lengthened (46 min vs. 75 min; p = 0.01) and scattered. The CT-treatment time halved (57 min vs. 30 min; p = 0.001), with consequent shortening of the 'door-to-needle' period (121 min vs. 90 min; p = 0.002). The arrival-CT time had remained constant (50 min vs. 53 min; p = 0.9), thus the total delay from onset did not change significantly (165 min vs. 170 min; p = 0.7), and the inverse linear correlation between the onset-CT time and the CT-treatment time weakened. CONCLUSIONS: Warnings against procrastination appear to be important in terms of shortening the delays. The time used for clinical-radiologic evaluation (arrival through CT)--about which there had been no action taken--had not been modified, but the time employed in the decision to treat (CT-treatment) and the 'door-to-needle' time had decreased appreciably. This effective compensatory reduction permitted treatment of late-arriving patients, such that although the overall time from onset to treatment apparently was not modified, the actual treatment rate increased.

[Sign of hyperdense and hyperintense anterior cerebral artery]. / Signo de la arteria cerebral anterior hiperdensa e hiperintensa.

INTRODUCTION: The sign of a hyperdense middle cerebral artery (MCA) in computed tomography (CT) scan, or hyperintense MCA in magnetic resonance imaging (MRI) has been associated with recent acute occlusion of the vessel. Hyperdense or hyperintense signs in the basilar and cerebral posterior arteries in association with acute infarct have also been reported. These signs may help to clarify localization and provide prognostic information, especially when the clinical findings are not clear or conclusive. We hereby report on a case of acute infarct in the anterior cerebral artery (ACA) territory with hyperdensity and hyperintensity of the affected vessel. CASE REPORT: This is a case report of a 74 year old male patient with vascular risk factors who had the acute onset of speech impairment and left side hemiparesis, evolving over the next several hours to include depression of the level of consciousness, mutism, and right leg paresis. The A2 segment of the right ACA was found to be hyperdense in CT scan without contrast, and hyperintense in the FLAIR-MRI respectively. MR-angiography showed occlusion of the probably dominant right ACA at the A2 segment shortly after its onset. CONCLUSIONS: The finding of a hyperdense and hyperintense ACA may be useful for diagnosis of acute stroke in the ACA territory, particularly in clinically ambiguous cases. To our knowledge, this is the first reported case of hyperdense and hyperintense ACA as an early sign of acute stroke. Its prognostic value in the ACA is thus far unknown.