Pretreatment diffusion-weighted imaging for prediction of relapsed and refractory primary central nervous system lymphoma.

Objectives: A subset of primary central nervous system lymphoma (PCNSL) has been shown to undergo an early relapsed/refractory (R/R) period after first-line chemotherapy. This study investigated the pretreatment clinical and MRI features to predict R/R in PCNSL, emphasizing the apparent diffusion coefficient (ADC) values in diffusion-weighted imaging (DWI). Methods: This retrospective study investigated the pretreatment MRI features for predicting R/R in PCNSL. Only patients who had undergone complete preoperative and postoperative MRI follow-up studies were included. From January 2006 to December 2021, 52 patients from two medical institutions with a diagnosis of PCNSL were included (median follow-up time, 26.3 months). Among these, 24 (46.2%) had developed R/R (median time to relapse, 13 months). Cox proportional hazard regression analyses were performed to determine hazard ratios for all parameters. Results: Significant predictors of R/R in PCNSL were female sex, complete response (CR) to first-line chemotherapy, and ADC value/ratio (p < 0.05). Cut-off points of ADC values and ADC ratios for prediction of R/R were 0.68 × 10-3 mm2/s and 0.97, with AUCs of 0.78 and 0.77, respectively (p < 0.05). Multivariate Cox proportional hazards analysis showed that failure of CR to first-line chemotherapy and low ADC values (<0.68 × 10-3 mm2/s) were significant risk factors for R/R, with hazard ratios of 5.22 and 14.45, respectively (p < 0.05). Kaplan-Meier analysis showed that lower ADC values and ratios predicted significantly shorter progression-free survival (p < 0.05). Conclusion: Pretreatment ADC values in DWI offer quantitative valuable information for the treatment planning in PCNSL.

Internal Derangement of the Shoulder Joint in Asymptomatic Professional Baseball Players.

RATIONALE AND OBJECTIVES: To evaluate the influence of throwing activity on shoulder morphology and the difference in shoulder morphology on MRI between asymptomatic professional baseball players and volunteers who play baseball as a recreational activity. MATERIALS AND METHODS: This retrospective case-control study included 68 asymptomatic professional baseball players (32 pitchers, 36 batters) and 30 male volunteers. Morphologic changes in the following shoulder structures were assessed on MRI: rotator cuff, glenoid labrum, humeral head, subacromial-subdeltoid bursa, subcoracoid bursa, long head of the biceps tendon, deltoid muscle, acromion, and clavicle. RESULTS: Partially torn supraspinatus, posterior glenoid or labral lesions, bone marrow edema, intraosseous cysts of the humeral head, and edematous subacromial-subdeltoid bursa were significantly more commonly observed in players (p = 0.01, p < 0.001, p = 0.03, p< 0.001, and p < 0.001). Players with more than 10 years of experience had a significantly higher incidence of patchy intermediate signal abnormality (odds ratio: 3.73, p = 0.03), partial tear in the supraspinatus tendon (odds ratio: 6.20, p = 0.03), and edematous change in the subacromial-subdeltoid bursa (odds ratio: 2.96, p = 0.03). CONCLUSION: The results from our study showed that repetitive throwing activities cause macroscopic structural lesions of the shoulder joints in asymptomatic baseball players. Significance of these lesions is to be determined.

Effects of High-Dose α-Lipoic Acid on Heart Rate Variability of Type 2 Diabetes Mellitus Patients with Cardiac Autonomic Neuropathy in Korea.

BACKGROUND: Diabetic cardiac autonomic neuropathy (CAN) is one of the important complications of diabetes. It is characterized by reduced heart rate variability (HRV). METHODS: In this randomized, double-blind, placebo-controlled, multicenter trial, 75 patients were randomly assigned to one of two groups. One group (n=41) received α-lipoic acid (ALA) at an oral dose of 600 mg/day for the first 12 weeks and then 1,200 mg/day for the next 12 weeks. The other group (n=34) received placebo treatment for 24 weeks. CAN was assessed by measuring HRVs in people with diabetes. RESULTS: Most of the baseline measures for HRVs were similar between the ALA and placebo groups. Although there were no statistically significant HRV changes in the ALA group compared to the placebo group after 24 weeks of trial, we found a positive tendency in some of the HRV parameters of the ALA group. The standard deviations of normal-to-normal RR intervals in the standing position increased by 1.87 ms in the ALA group but decreased by -3.97 ms in the placebo group (P=0.06). The power spectrum of the low frequency (LF) band in the standing position increased by 15.77 ms² in the ALA group, whereas it declined by -15.04 ms² in the placebo group (P=0.08). The high frequency/LF ratio in the upright position increased by 0.35 in the ALA group, whereas it declined by -0.42 in the placebo group (P=0.06). There were no differences between the two groups regarding rates of adverse events. CONCLUSION: Although a slight improvement tendency was seen in HRV in the ALA group, there were no statistically significant HRV changes in the ALA group compared to the placebo group after 24 weeks of trial. However, the high oral dose of ALA was well-tolerated.

Efficacy of Body Weight Reduction on the SGLT2 Inhibitor in People with Type 2 Diabetes Mellitus.

BACKGROUND: Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, reduces hyperglycemia and body weight by inhibiting renal glucose reabsorption. However, only a few studies have demonstrated efficacy of dapagliflozin for type 2 diabetic patients in Korea. We evaluated the efficacy and safety of dapagliflozin for Korean type 2 diabetes patients. METHODS: This is a retrospective study that included data from 61 patients who received 12 months of dapagliflozin therapy and who visited a single medical center between January 2015 and July 2016. Patients were separated into three groups: dual combination of dapagliflozin and metformin, triple combination of dapagliflozin and metformin with sulfonylurea, or dipeptidyl peptidase IV inhibitors, and quadriple combination of dapagliflozin, metformin, and sulfonylurea with dipeptidyl peptidase IV inhibitors. Patients who achieved ≥5% body weight reduction were classified as responders, and those who achieved <5% body weight reduction were classified as non-responders. RESULTS: After 12 months, the mean change from baseline body weight was -3.4±2.6 kg (P<0.001) for all patients, -3.4±3.1 kg (P<0.001) for group 1, -2.7±2.0 kg (P=0.008) for group 2, and -4.0±2.3 kg (P<0.001) for group 3. Fasting C-peptide level was higher in the responder group than in the non-responder group (3.25±1.07 ng/mL vs. 2.62±1.02 ng/mL, P=0.023). In total, reductions in HbA1c, PP2, and FPG levels were -0.61±0.82% (P=0.000), -35.4±62 mg/dL (P=0.000), and -21.3±56.2 mg/dL (P=0.012), respectively. They had mild adverse events included orthostatic dizziness and urinary tract infection. CONCLUSION: SGLT2 inhibitor improved glycemic control and reduced body weight in a safe manner for patients with type 2 diabetes mellitus.

Differentiation between Glioblastoma Multiforme and Primary Cerebral Lymphoma: Additional Benefits of Quantitative Diffusion-Weighted MR Imaging.

The differentiation between glioblastoma multiforme (GBM) and primary cerebral lymphoma (PCL) is important because the treatments are substantially different. The purpose of this article is to describe the MR imaging characteristics of GBM and PCL with emphasis on the quantitative ADC analysis in the tumor necrosis, the most strongly-enhanced tumor area, and the peritumoral edema. This retrospective cohort study collected 104 GBM (WHO grade IV) patients and 22 immune-competent PCL (diffuse large B cell lymphoma) patients. All these patients had pretreatment brain MR DWI and ADC imaging. Analysis of conventional MR imaging and quantitative ADC measurement including the tumor necrosis (ADCn), the most strongly-enhanced tumor area (ADCt), and the peritumoral edema (ADCe) were done. ROC analysis with optimal cut-off values and area-under-the ROC curve (AUC) was performed. For conventional MR imaging, there are statistical differences in tumor size, tumor location, tumor margin, and the presence of tumor necrosis between GBM and PCL. Quantitative ADC analysis shows that GBM tended to have significantly (P<0.05) higher ADC in the most strongly-enhanced area (ADCt) and lower ADC in the peritumoral edema (ADCe) as compared with PCL. Excellent AUC (0.94) with optimal sensitivity of 90% and specificity of 86% for differentiating between GBM and PCL was obtained by combination of ADC in the tumor necrosis (ADCn), the most strongly-enhanced tumor area (ADCt), and the peritumoral edema (ADCe). Besides, there are positive ADC gradients in the peritumoral edema in a subset of GBMs but not in the PCLs. Quantitative ADC analysis in these three areas can thus be implemented to improve diagnostic accuracy for these two brain tumor types. The histological correlation of the ADC difference deserves further investigation.

Preoperative embolization of carotid body tumor by direct percutaneous intratumoral injection of N-butyl cyanoacrylate glue assisted with balloon protection technique.

Substantial intraoperative bleeding during surgical removal of carotid body tumor may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial access has proved effective but is often limited by complex vascular anatomy and small feeding vessels that is difficult to catheterize. We report two cases of carotid body tumor treated with direct puncture and intratumoral injection of N-butyl cyanoacrylate glue (NBCA) assisted with balloon protection technique for preoperative devascularization. The result was impressive and minimal bleeding loss during surgery was observed.

Longitudinal study of carbon monoxide intoxication by diffusion tensor imaging with neuropsychiatric correlation.

BACKGROUND: White matter damage is common after carbon monoxide (CO) intoxication, but in vivo follow-up studies about the mechanism of white matter damage are not possible in pathology series. Diffusion tensor imaging (DTI) and voxel-based morphometry (VBM) can quantify diffusion parameters and volumetric changes in white matter that can be correlated with neuropsychological performances in longitudinal studies. METHODS: We examined 9 patients with CO intoxication using DTI, VBM and neuropsychologic tests at an average of 3 and 10 months after CO exposure. We used data from 18 age- and sex-matched controls for comparison. RESULTS: We found that cognitive recovery at 10 months after CO intoxication was not significant, although it was after 3 months. The neuropsychologic tests correlated better for the fibre tract of the semicentrum ovale and not the periventricular fibres. Diffusion measures suggest increases in fractional anisotropy, mean diffusivity and axial eigenvalues over time, while increases in radial eigenvalue were evident at 3 months compared with controls. Periventricular white matter atrophy was observed 10 months after CO intoxication. LIMITATIONS: Our study included few cases, and the interpretation of the putative changes on neuroimaging findings cannot be confirmed by histology. CONCLUSION: Our study showed that the evolution of white matter injury in CO encephalopathy occurred over time. Cognitive recovery was not evident in the follow-up period because of white matter injuries.

Damage of white matter tract correlated with neuropsychological deficits in carbon monoxide intoxication after hyperbaric oxygen therapy.

Carbon monoxide (CO) intoxication can result in cognitive deficits and demyelinating changes of the white matter (WM), for which hyperbaric-oxygen (HBO) treatment is considered effective in reducing neuropsychiatric symptoms. This study aimed to analyze cognitive functions and WM diffusion properties in CO intoxication after standard HBO treatment. Seventeen CO intoxicated patients were evaluated 4-6 months after HBO treatment. They also underwent diffusion tensor imaging (DTI) and cognitive assessment, and the results were compared with those from 34 age-matched controls. DTI was transformed into fractional anisotropy (FA) and mean diffusivity (MD) and assessed at every voxel level with tract-based spatial statistics across the brain. Correlation between reduced FA and increased MD with neuropsychological deficits were performed. Cognitive results showed that impairment in executive function, as well as verbal and visual memories, were most prominent. There were extensive areas of increased MD and decreased FA. Correlation analyses showed that memory retrieval, judgment, and verbal generation tasks were related to FA of the frontotemporal WM. MD showed weaker correlation with cognitive deficits. These data suggest that neurologic deficits and WM changes are detectable 4-6 months after HBO therapy. The correlation of WM diffusion with cognitive deficits also suggests that reduced connectivity between different cortical regions is a pathophysiologic mechanism.

Retroperitoneal hemorrhage caused by enoxaparin-induced spontaneous lumbar artery bleeding and treated by transcatheter arterial embolization: a case report.

Lumbar artery bleeding with retroperitoneal hematoma is an uncommon life-threatening complication secondary to enoxaparin use. We present a case of 73-year-old Chinese woman with acute retroperitoneal hemorrhage one month following hip surgery, due to enoxaparine. Enoxaparin induced hemorrhage caused by spontaneous rupture of lumbar artery was suspected and treated successfully by transcatheter arterial embolization.

New vertebral osteoporotic compression fractures after percutaneous vertebroplasty: retrospective analysis of risk factors.

PURPOSE: To investigate risk factors for new vertebral compression fractures (VCFs) after vertebroplasty. MATERIALS AND METHODS: The authors analyzed the occurrence of new VCFs in 70 patients who had previously undergone vertebroplasty for the treatment of one VCF. The following covariates were analyzed: age, sex, body weight, height, body mass index (BMI), treated vertebral level, relative distance between treated vertebrae and new VCFs, pre-existing untreated VCFs, gas-containing vertebrae before treatment, and surgical approach. Surgical variables, including cement leakage into the disk, anterior vertebral height restoration, and kyphosis correction of treated vertebrae were also analyzed. A Cox proportional hazards regression analysis was used to determine the relative risk of new adjacent VCFs. The Kaplan-Meier method was used to calculate mean fracture-free rate over time. RESULTS: Seventy patients were reviewed, with a mean follow-up of 20.0 months +/- 10.2 (range, 6-48 months). We identified 22 new fractures in 19 of the 70 patients (27%), with 16 adjacent and six nonadjacent VCFs. The mean time to new fracture was 10.6 months +/- 9.5, and there was no significant difference in time to adjacent or nonadjacent VCF. Increased risk of VCF was associated with proximity to the treated vertebra, greater kyphosis correction, and low patient BMI. The 1-year fracture-free rate was 79.5%. CONCLUSIONS: New VCFs are common in patients with a low BMI, which suggests osteoporosis as a mechanism of fracture.

Refractures in cemented vertebrae after percutaneous vertebroplasty: a retrospective analysis.

Percutaneous vertebroplasty is an efficient procedure to treat pain due to osteoporotic vertebral compression fractures. However, refracture of cemented vertebrae occurs occasionally after vertebroplasty. It is unclear whether such fractures are procedure-related or part of the natural course of osteoporosis. The effect of potentially important covariates on refracture risk in cemented vertebrae has not been evaluated previously. We retrospectively analyzed the incidence and possible causative mechanism of refracture in patients who had received only one vertebroplasty for a single level of vertebral compression fracture. We assessed the following covariates: age, sex, body weight, height, lumbar spine bone mineral density, treated vertebral level, pre-existing untreated vertebral compression fracture, and gas-containing vertebrae before treatment. Surgical variables, including surgical approach, cement injected, and anterior vertebral height restoration, were also analyzed. Anti-osteoporotic treatment after surgery was recorded. Multiple logistic regression analysis was used to determine the relative risk of refractures of cemented vertebrae. Over all, 98 patients were evaluated with a mean follow-up of 26.9 +/- 12.4 months (range, 7-55 months). We identified 62 refractures and the mean loss of anterior vertebral height was 13.3% (range 3.2-40.3%). The greater the anterior vertebral height obtained from vertebroplasty, the greater the risk of refracture occurring (P < 0.01). Gas-containing vertebrae were also prone to refracture after the procedure (P = 0.01). Anti-osteoporotic treatment was of borderline significance between refractured and non-refractured vertebrae (P = 0.07). Only restoration of anterior vertebral height was positively associated with refracture during the follow-ups (P < 0.01). In conclusion, refractures of cemented vertebrae after vertebroplasty occurred in 63% of osteoporotic patients. Significant anterior vertebral height restoration increases the risk of subsequent fracture in cemented vertebrae.

Leukoencephalopathy associated with dialysis disequilibrium syndrome.

Dialysis disequilibrium syndrome (DDS) is usually seen in severely uremic patients who are dialyzed aggressively. DDS mostly appeared within 24 hours after hemodialysis (HD) and may last for a few hours. This diagnosis is made by the exclusion of other causes including metabolic and intracranial events and has been recognized for more than 40 years. Few reports described the cerebral radiographic features associated with DDS. We present an 83-year-old uremic patient experiencing DDS at initial HD. DDS-related cerebral radiographic manifestations reported in the literature are reviewed, along with a discussion of the role of neuroimaging in the diagnosis of DDS.

Right anterior cingulate cortex infarction and transient speech aspontaneity.

BACKGROUND: According to recent functional studies, the medial frontal lobe of the dominant hemisphere plays a role in both word generation and speech initiation. To our knowledge, speech arrest with intact facial expression secondary to the right anterior cingulate cortex (ACC) lesion has not been previously reported. OBJECTIVE: To report 2 cases of speech initiation difficulties associated with a stroke of the right anterior cingulate gyrus with magnetic resonance imaging with tractography results. DESIGN: Two case reports. SETTING: Inpatient neurology clinic at a university medical center. Patients Two women who had acute and transient speech initiation problems. RESULTS: Speech evaluation revealed pure speech initiation difficulties with intact facial praxis and expression. In the patient who could be tested, writing ability was preserved. In addition to acute right ACC infarction, the magnetic resonance imaging also revealed anterior corpus callosum and/or posterior corpus callosum involvement. Tractography in patient 2 revealed fibers from the right ACC that would cross to the contralateral side. Reduced fiber numbers connecting the right supplementary motor area with the ACC were also observed, which differed from the left ACC tractography. CONCLUSIONS: To our knowledge, this is the first case series of right ACC stroke with transient speech initiation problems. Because of the rare findings of the tractography, we suggest that in some patients, speech initiation required the participation of the right ACC in addition to the language network of the left hemisphere.

Idiopathic hypertrophic cranial pachymeningitis: case report with 7 years of imaging follow-up.

Idiopathic hypertrophic cranial pachymeningitis is a rare inflammatory disease with diffused involvement of the dura. Often, the definite diagnosis is made immediately with biopsy and the involved dura is removed surgically. Consequently, extensive preoperative imaging studies usually are not available. We reviewed a case of idiopathic hypertrophic cranial pachymeningitis and collectively summarized the interesting features from the 7 years preceding surgical treatment. These chronologic imaging findings with progressive intracranial involvement included dural thickening, dural mass, sinus thrombosis, and venous congestion constituted comprehensive pictures of idiopathic hypertrophic cranial pachymeningitis. The thickened dura may also at times mimic dural masses, such as en plaque meningioma.