Bertolotti syndrome: a not-to-miss cause of chronic low back pain in young adults.

Low back pain (LBP) in young adults is a common condition that needs to be appropriately examined in cases of refractory to classic treatment strategies. We present two cases of chronic LBP with challenging diagnosis and treatment refractoriness. The first case corresponds to a young lady that has been treated mistakenly with an anti-tumor necrosis factor because her treating doctors diagnosed unilateral sacroiliitis which turned out to be a magnetic resonance imaging (MRI) artifact (partial volume artifact). The second case is about another young lady with chronic LBP that did not respond to the classic treatment with non-steroidal anti-inflammatory drugs. Both cases have been diagnosed as having Bertolotti syndrome. Bertolotti syndrome is an anatomical abnormality consisting of partial unilateral or bilateral fusion of the transverse process of the lowest lumbar vertebrae to the sacrum. The presentation of both cases highlights the importance of a minute history taking and clinical examination especially in young patients with chronic LBP.

Functional and structural connectivity of the brain in very preterm babies: relationship with gestational age and body and brain growth.

BACKGROUND: Structural and functional changes of the brain have been reported in premature babies. OBJECTIVE: To evaluate the relationship of functional and structural connectivity with gestational age, body growth and brain maturation in very preterm babies. MATERIALS AND METHODS: We studied 18 very preterm babies (gestational age: mean ± standard deviation, 29.7±1.7 weeks). We examined functional connectivity by multivariate pattern analysis of resting-state functional MRI data. We assessed structural connectivity by analysis of diffusion tensor imaging data and probabilistic tractography. RESULTS: The average functional connectivity of the medial orbitofrontal cortex with the rest of the brain was positively associated with gestational age (P<0.001). Fractional anisotropy of the right inferior fronto-occipital fasciculus was positively associated with head circumference at term-equivalent age. Structural connectivity of the inferior fronto-occipital fasciculus with the medial orbitofrontal cortex was positively associated with head circumference at term-equivalent age. Body weight at term-equivalent age was the only independent predictor of average structural connectivity of the medial orbitofrontal cortex with the rest of the brain (P=0.020). CONCLUSION: Structural and functional connectivity of the medial orbitofrontal cortex with the rest of the brain depend on body growth and degree of prematurity, respectively.

The association between multiple sclerosis and spondylosis: When and why.

OBJECTIVES: To evaluate risk factors for the development of cervical spine spondylosis (CSS) in patients with multiple sclerosis (MS) and to propose a pathogenetic mechanism. METHODS: Forty-two consecutive patients aged 23-66 years with MS and 42 age and sex matched controls were evaluated retrospectively; Clinical disability was evaluated with the expanded disability status scale (EDSS) and spasticity with the Asworth score. Total brain lesion volume (BLV), total grey matter (GM) volume and deep GM volume were assessed. In the cervical spine CSS indices (disk dehydration, disk protrusion, abnormal posture and osteophytosis) and the spinal cord lesion load (SLL) was evaluated. The association of CSS indices with the presence of MS, the clinical scales and the brain and spinal cord imaging measurements were assessed. RESULTS: Presence of MS was positively associated with abnormal posture (P=0.002), disk dehydration at C6-C7 (P=0.049) and posterior disk protrusion at C5-C6 (P=0.033) and C6-C7 (P=0.001). All patients had spasticity. Patients with abnormal posture were younger (37.5±11.1years) than those with normal (45.4±8.6years), P=0.024. Age (P=0.008), EDSS (P=0.045) and BLV (P=0.084) were significant independent predictors of abnormal posture. Younger age combined with worse EDSS and increased BLV predicted abnormal posture. CONCLUSIONS: Patients with MS present more frequently spondylosis which is associated with younger age, more severe disability and extensive lesions in the brain. Spasticity induced by the brain lesions and abnormal expression of extracellular matrix proteins in the brain and the intervertebral disk constitute a possible pathogenetic mechanism.

The role of diffusion tensor imaging and dynamic susceptibility perfusion MRI in the evaluation of meningioma grade and subtype.

PURPOSE: We prospectively investigated the relationship between diffusion tensor imaging (DTI), dynamic susceptibility perfusion (DSP) MRI metrics and grade, subtype and Ki-67 labelling index of meningiomas. MATERIALS AND ΜETHODS: Thirty-nine patients operated for meningioma were included in the study. DTI and DSP were performed within a week prior to surgical excision. Lesion/normal (L/N) tissue ratios and peritumoral area/normal tissue (P/N) ratios were calculated for the apparent diffusion coefficient (ADC), fractional anisotropy (FA) and relative cerebral blood volume (rCBV). In the tumor specimens Ki-67 antigen expression was evaluated by the MIB-1 immunostaining method. RESULTS: There were 31 grade I, 7 grade II and one grade III meningiomas. Grade I meningiomas had a significantly lower L/N rCBV ratios than grade II/III meningiomas (median 5.1 vs 6.4, p=0.031). Grade I meningiomas revealed significantly lower P/N rCBV ratios than grade II/III meningiomas (median 0.78 vs 1.1, p=0.0077). Grade I meningiomas had significantly higher FA ratios than grade II/III meningiomas (median 0.5 vs 0.31, p=0.012). Meningiomas of meningothelial type had a significantly higher L/N rCBV ratio than other grade I meningiomas (median 5.4 vs 3.8, p=0.0136). There was no significant correlation between rCBV, ADC, FA and Ki-67 index. CONCLUSION: Dynamic susceptibility perfusion indexes in lesion/normal and peritumoral/normal tissue ratios are useful for the differentiation grade I from grade II/III menigiomas. Meningothelial meningiomas showed higher lesion/normal tissue rCBV ratios from the other benign meningioma subtypes.

Does this patient have hypertensive encephalopathy?

A 63-year-old man was admitted to our hospital for further investigation and management of brain metastases. The patient was initially presented with a 4-day history of confusion. On the day of admission, the patient was confused, agitated, disorientated in place and time, and had visual disturbances. His blood pressure was repeatedly recorded high, with levels of systolic blood pressure between 170-210 mm Hg. A brain magnetic resonance imaging showed areas of high signal on T2 and fluid-attenuated inversion recovery images, located bilaterally in the white matter of the occipital regions and unilateral in the left frontal lobe, suggestive of posterior reversible encephalopathy syndrome. Aggressive treatment of hypertension resulted in complete resolution of the clinical and radiologic features of the syndrome.

Multimodal imaging evaluation of excessive daytime sleepiness in Parkinson's disease.

PURPOSE OF THE STUDY: The multimodal imaging investigation of excessive daytime sleepiness (EDS) in Parkinson's disease (PD). The role of dopaminergic treatment and other clinical parameters was also evaluated. MATERIALS AND METHODS: Seventeen non-demented PD patients with EDS (PD-EDS) and 17 PD patients without EDS were enrolled. Clinical, treatment and MRI data were acquired. Gray matter (GM) volume was examined with voxel-based morphometry, while white matter (WM) integrity was assessed with diffusion tensor imaging by means of fractional anisotropy, mean diffusivity, axial diffusivity (AD) and radial diffusivity measures. RESULTS: Increased regional GM volume was found in the PD-EDS group bilaterally in the hippocampus and parahippocampal gyri. Increased AD values were also shown in the PD-EDS group, in the left anterior thalamic radiation and the corticospinal tract and bilaterally in the superior corona radiata and the superior longitudinal fasciculus. Levodopa equivalent dose differed significantly between the groups and was the only predictor of EDS, while the only predictor of the Epworth sleepiness scale score in the PD-EDS group was the dopamine-agonist dose. Increased frequency of gamblers was also observed in the PD-EDS group. CONCLUSIONS: Regional GM increases and increased AD values in certain WM tracts were found in the PD-EDS group. The changes could result from disinhibited signaling pathways or represent compensatory changes in response to anatomical or functional deficits elsewhere. The study findings support also the contribution of the total dopaminergic load in the development of EDS, while the dose of dopamine agonists was found to predict the severity of the disorder.

Correlation of diffusion tensor and dynamic susceptibility contrast MRI with DNA ploidy and cell cycle analysis of gliomas.

OBJECTIVES: Flow cytometry provides a powerful tool to assess cells in G0/G1, S and G2/M phase and ploidy. The purpose of the present study was to investigate the correlation between diffusion tensor (DTI) and dynamic susceptibility contrast (DSC) MRI metrics with cell cycle analysis findings in gliomas. PATIENTS AND METHODS: We studied thirty patients who were operated on for glioma. DTI and DSC MRI were performed within a week prior to surgical excision. Lesion/normal ratios were calculated for the ADC, FA and rCBV. In an excised tumour sample flow cytometric analysis was performed. RESULTS: There were 24 glioblastomas, 2 anaplastic astrocytomas, 1 oligoastrocytoma and 3 diffuse astrocytomas. There were significant differences between low and high-grade gliomas for rCBV and ADC values. Low grade tumours had higher G0/G1 phase fraction and lower S-phase, G2/M, S+G2/M and S+G2/M/G0/G1 fractions There was a significant negative correlation between rCBV and G0/G1 phase fraction and a positive correlation with G2/M, S+G2/M and the S+G2/M/G0/G1 fraction. Significant correlation was also observed between FA ratio and S+G2/M/G0/G1. There was a negative significant correlation between ADC and S+G2/M and the S+G2/M/G0/G1 fraction. There were 21 (70%) diploid and 9 (30%) aneuploid tumours. No significant difference was found between diploid and aneuploid tumours with respect to rCBV, ADC and FA values. CONCLUSION: Dynamic susceptibility contrast MRI and diffusion tensor imaging metrics are correlated to tumour aggressiveness as assessed by cell cycle analysis.

Tuberculous pyomyositis in a rheumatoid arthritis patient treated with anakinra.

Musculoskeletal tuberculosis (TB) occurs in only 3% of patients with TB while tuberculous pyomyositis is rare. It usually affects immunocompromised or patients with underlying comorbidities. We present a case of tuberculous pyomyositis in a 85-year-old Caucasian patient with rheumatoid arthritis (RA) treated with steroids and anakinra. The patient presented with fever as well as redness, swelling and induration on the lateral side of the hip and thigh. Under ultrasound guidance fluid collection of the thigh was aspirated. Polymerase chain reaction (PCR) and cultures of the fluid were positive for Mycobacterium TB. The patient underwent bronchoscopy. PCR and cultures from the bronchoalveolar lavage were also positive for Mycobacterium TB. The patient was treated with anti TB treatment with amelioration of the inflammation in the hip and thigh. This is the first reported case of tuberculous pyomyositis in a RA patient treated with anakinra.

Intra-articular post-traumatic ankle joint mass imitating localized pigmented villonodular synovitis (LPVS), the aid of ankle arthroscopy for diagnosis and treatment-a case report.

Intra-articular post-traumatic ankle joint mass is a rare entity that may mimic other pathologies, mainly localized form of pigmented villonodular synovitis (LPVS) regarding the clinical and imaging characteristics. We report the case of a 16-year-old female patient that presented an intra-articular ankle joint mass 8 months after an ankle joint sprain for which magnetic resonance imaging (MRI) suggested LPVS as possible diagnosis due to the presence of hemosiderin deposits. Diagnosis of a post-traumatic hematoma of her ankle joint was made via fine needle aspiration (FNA) biopsy and anterior ankle arthroscopy. At one-year-follow-up after the arthroscopic excision of the hematoma, the patient remained asymptomatic and pain free while MRI revealed no pathologic findings. This case demonstrates that LPVS is not always the diagnosis when hemosiderin deposits are depicted on the MRI of a solitary intra-articular mass. The FNA biopsy under direct arthroscopic view assists the diagnosis and guides the treatment plan in cases that no definite diagnosis has been reached preoperatively by MRI. Level of evidence IV, case report.

Comparison of diffusion tensor, dynamic susceptibility contrast MRI and (99m)Tc-Tetrofosmin brain SPECT for the detection of recurrent high-grade glioma.

INTRODUCTION: Treatment induced necrosis is a relatively frequent finding in patients treated for high-grade glioma. Differentiation by imaging modalities between glioma recurrence and treatment induced necrosis is not always straightforward. This is a comparative study of diffusion tensor imaging (DTI), dynamic susceptibility contrast MRI and (99m)Tc-Tetrofosmin brain single-photon emission computed tomography (SPECT) for differentiation of recurrent glioma from treatment induced necrosis. METHODS: A prospective study was made of 30 patients treated for high-grade glioma who had suspected recurrent tumor on follow-up MRI. All had been treated by surgical resection of the tumor followed by standard postoperative radiotherapy with chemotherapy. No residual tumor had been found on brain imaging immediately after the initial treatment. All the patients were studied with dynamic susceptibility contrast brain MRI and, within a week, (99m)Tc-Tetrofosmin brain SPECT. RESULTS: Both (99m)Tc-Tetrofosmin brain SPECT and dynamic susceptibility contrast MRI could discriminate between tumor recurrence and treatment induced necrosis with 100% sensitivity and 100% specificity. An apparent diffusion coefficient (ADC) ratio cut-off value of 1.27 could differentiate recurrence from treatment induced necrosis with 65% sensitivity and 100% specificity and a fractional anisotropy (FA) ratio cut-off value of 0.47 could differentiate recurrence from treatment induced necrosis with 57% sensitivity and 100% specificity. A significant correlation was demonstrated between (99m)Tc-Tetrofosmin uptake ratio and rCBV (P=0.003). CONCLUSIONS: Dynamic susceptibility contrast MRI and brain SPECT with (99m)Tc-Tetrofosmin had the same accuracy and may be used to detect recurrent tumor following treatment for glioma. DTI also showed promise for the detection of recurrent tumor, but was inferior to both dynamic susceptibility contrast MRI and brain SPECT.

Body growth and brain development in premature babies: an MRI study.

BACKGROUND: Prematurity and intrauterine growth restriction are associated with neurodevelopmental disabilities. OBJECTIVE: To assess the relationship between growth status and regional brain volume (rBV) and white matter microstructure in premature babies at around term-equivalent age. MATERIALS AND METHODS: Premature infants (n= 27) of gestational age (GA): 29.8 ± 2.1 weeks, with normal brain MRI scans were studied at corrected age: 41.2 ± 1.4 weeks. The infants were divided into three groups: 1) appropriate for GA at birth and at the time of MRI (AGA), 2) small for GA at birth with catch-up growth at the time of MRI (SGAa) and 3) small for GA at birth with failure of catch-up growth at the time of MRI (SGAb). The T1-weighted images were segmented into 90 rBVs using the SPM8/IBASPM and differences among groups were assessed. Fractional anisotropy (FA) was measured bilaterally in 15 fiber tracts and its relationship to GA and somatometric measurements was explored. RESULTS: Lower rBV was observed in SGAb in superior and anterior brain areas. A positive correlation was demonstrated between FA and head circumference and body weight. Body weight was the only significant predictor for FA (P< 0.05). CONCLUSION: In premature babies, catch-up growth is associated with regional brain volume catch-up at around term-equivalent age, starting from the brain areas maturing first. Body weight seems to be a strong predictor associated with WM microstructure in brain areas related to attention, language, cognition, memory and executing functioning.

Correlation of diffusion tensor, dynamic susceptibility contrast MRI and (99m)Tc-Tetrofosmin brain SPECT with tumour grade and Ki-67 immunohistochemistry in glioma.

OBJECTIVE: Assessment of the grade and type of glioma is of paramount importance for prognosis. Tumour proliferative potentials may provide additional information on the behaviour of the tumour, its response to treatment and prognosis. The purpose of this study was to investigate the correlation between diffusion tensor imaging (DTI), dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) and (99m)Tc-Tetrofosmin brain single-photon emission computed tomography (SPECT), and the tumour grade and Ki-67 labelling index in newly diagnosed gliomas. METHODS: Study was made of patients with suspected glioma on brain MRI between December 2010 and January 2012, by DTI, DSC MRI and (99m)Tc-Tetrofosmin brain SPECT. The proliferative activity of each tumour was measured by deriving the Ki-67 proliferation index from immunohistochemical staining of tumour specimens. RESULTS: Glioma was newly diagnosed in 25 patients (17 men, 8 women, aged 19-79 years, median 55 years). The Ki-67 index ranged from 1% to 80% (mean 19.4%). On evaluation of the relationship between the (99m)Tc-Tetrofosmin tumour uptake by gliomas was found to be significantly correlated with cellular proliferation (rho=0.924, p<0.0001). Regarding DTI, significant negative correlation was demonstrated between the apparent diffusion coefficient (ADC) ratio and the Ki-67 index (rho=-0.545, p=0.0087). Significant correlation was also observed between the fractional anisotropy (FA) ratio and the Ki-67 index (rho=0.489, p=0.02). Strong correlation was found between relative cerebral blood volume (rCBV) and Ki-67 index (rho=0.853, p<0.0001), and between the (99m)Tc-Tetrofosmin lesion-to-normal (L/N) uptake ratio and rCBV (rho=0.808, p ≤ 0.0001). Significant negative correlation was demonstrated between the (99m)Tc-Tetrofosmin L/N ratio and ADC ratio (rho=-0.513, p=0.014). These imaging techniques were able to distinguish between low-grade and high-grade gliomas. CONCLUSIONS: Findings on DSC MRI and brain SPECT with (99m)Tc-Tetrofosmin metrics were more closely correlated with glioma cellular proliferation.

Diffusion tensor and dynamic susceptibility contrast MRI in glioblastoma.

OBJECTIVE: We prospectively investigated the correlation between diffusion tensor (DTI), dynamic susceptibility contrast (DSC) perfusion MRI metrics and Ki-67 labelling index in glioblastomas. METHODS: We studied seventeen patients who were operated on for glioblastoma. DTI and DSC MRI were performed within a week prior to surgical excision. Lesion/normal ratios were calculated for the apparent diffusion coefficient (ADC), fractional anisotropy (FA), relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF) and relative mean transit time (rMTT) ratio. In the excised tumour specimens Ki-67 antigen expression was evaluated by the MIB-1 immunostaining method. RESULTS: A significant correlation was observed between Ki-67 index and ADC ratio (r = -0.528, p = 0.029) and FA ratio (r = 0.589, p = 0.012). rCBV and rMTT presented a trend towards significant correlation with Ki-67 index (r = 0.628, p = 0.07 and r = 0.644, p = 0.06 respectively). There was a trend towards better survival for patients with gross total tumour excision and FA values lower than 0.48 (p = 0.1 and p = 0.09 respectively). No significant correlation was found between ADC ratio, rCBV, rCBF, rMTT and overall survival. CONCLUSION: ADC ratio, FA ratio, rCBV and rMTT tumour/normal tissue ratios may represent indicators of glioma proliferation. FA values may hold promise for predicting survival in patients with glioblastoma.

The usefulness of magnetic resonance imaging of the hand and wrist in very early rheumatoid arthritis.

INTRODUCTION: Magnetic resonance imaging (MRI) was used to study the hand and wrist in very early rheumatoid arthritis (RA), and the results were compared with early and established disease. METHODS: Fifty-seven patients fulfilling the new American College of Rheumatology criteria for RA, 26 with very early RA (VERA), 18 with early RA (ERA), and 13 with established RA (ESTRA), (disease duration < 3 months, < 12 months, and > 12 months, respectively) were enrolled in the study. MRI of the dominant hand and wrist was performed by using fat-suppressed T2-weighted and plain and contrast-enhanced T1-weighted sequences. Evaluation of bone marrow edema, synovitis, and bone erosions was performed with the OMERACT RA MRI scoring system. RESULTS: Edema, erosions, and synovitis were present in VERA, and the prevalence was 100%, 96.15%, and 92.3%, respectively. Significant differences in edema and erosions were found between VERA and ESTRA (P < 0.05). No significant difference was found in synovitis. CONCLUSIONS: Edema, erosions, and synovitis are findings of very early RA. MRI, by detecting these lesions, may play an important role in the management of these patients.

Haemodynamic and renal effects of tadalafil in patients with cirrhosis.

A recent report introduced the phosphodiesterase-5 inhibition by vardenafil as a novel treatment of portal hypertension in patients with cirrhosis. In the herein presented "letter to the editor", the administration of tadalafil did not influence portal haemodynamics but impaired systemic haemodynamics in patients with cirrhosis. Our observations concur with the results of a report in a previous issue of World Journal of Gastroenterology (October 2008). Moreover, tadalafil adversely affected renal function in patients with decompensated liver disease.

Intramuscular hemangioma of the foot: A case report and review of the literature.

Intramuscular hemangiomas (IHs) are rare benign neoplasms usually seen in children, adolescents and young adults. Although lower extremities are the commonest localization, the localization at the foot is extremely rare since only a few cases have been reported. We report a case of mixed type IH of the flexor digitorum brevis muscle in a 12-year-old boy who was treated with surgical excision, with wide surgical margins.

Periventricular leukomalacia in preterm children: assessment of grey and white matter and cerebrospinal fluid changes by MRI.

BACKGROUND: Brain plasticity in patients with periventricular leukomalacia (PVL) may suggest grey matter (GM) changes. OBJECTIVE: To assess the volume of 116 GM areas and total volume of GM, white matter (WM) and cerebrospinal fluid (CSF) in preterm children with PVL, using the Statistical Parametric Mapping (SPM5) and the Individual Brain Atlases Statistical Parametric Mapping (IBASPM) toolboxes. MATERIALS AND METHODS: Ten preterm children (gestational age 31.7 +/- 4.2 weeks, corrected age 27.8 +/- 21.7 months) with PVL and 46 matched, preterm control subjects were studied using a three-dimensional T1-weighted sequence. Volumes were calculated using SPM5 and IBASPM. RESULTS: GM volume in frontal superior orbital, posterior cingulum and lingual gyrus, the putamen and thalamus was significantly higher in children with PVL (3.6 +/- 0.6 cm(3), 2.0 +/- 0.5 cm(3), 9.7 +/- 1.7 cm(3), 2.5 +/- 0.6 cm(3), 2.6 +/- 0.9 cm(3), respectively) than in controls (3.1 +/- 0.7 cm(3), 1.5 +/- 0.2 cm(3), 8.2 +/- 1.3 cm(3), 1.7 +/- 1.4 cm(3), 1.8 +/- 0.4 cm(3), respectively). White matter volume was lower (182.1 +/- 40.5 cm(3)) and CSF volume was higher (300.8 +/- 56.2 cm(3)) in children with PVL than in controls (222.9 +/- 67.2 cm(3), 219.0 +/- 61.8 cm(3), respectively), P < 0.05. No significant difference was found in the total GM volume and the volume of neocortex. CONCLUSION: Preterm children with PVL show regional GM volume increase, possibly explained by axonal sprouting, neuronal hypertrophy and neurogenesis, which in turn may reflect brain plasticity.

Temporomandibular joint involvement in juvenile idiopathic arthritis: clinical predictors of magnetic resonance imaging signs.

The aim of the study was to define clinical predictors of magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA). Forty-six patients, aged 2.08-36.7 years, with JIA (oligoartitular 18, polyarticular 17, systemic type 11) were examined with standard plain and contrast-enhanced sequences. Of 88 TMJs examined, an abnormal condyle was observed in 32%, flattened articular eminence in 27%, flattened articular disk in 17%, intra-articular fluid in 10%, enhancing pannus in 45% and restricted condylar motion in 9%. Logistic regression analysis revealed that for abnormal condyle and flattened articular eminence, independent predictors were type of JIA (P < 0.015), age at onset (P < 0.038), and duration of disease activity (P < 0.001). Plots of the logistic regression models showed that TMJ involvement approached certainty for systemic sooner than for the other JIA types. Pannus was present with probability >0.5 when the disease started before 4 years of age. In conclusion, the systemic type of JIA, young age at onset and long duration of activity are risk factors for TMJ damage. MRI of the TMJ should be performed in patients who are less than 4 years of age at the onset of JIA, and in those with the systemic type, whatever the age of onset.