Variability of Normal Pressure Hydrocephalus Imaging Biomarkers with Respect to Section Plane Angulation: How Wrong a Radiologist Can Be?

BACKGROUND AND PURPOSE: Systematic analysis of angulation-related variability of idiopathic normal pressure hydrocephalus imaging biomarkers has not been published yet. Our aim was to evaluate the variability of these radiologic biomarkers with respect to imaging plane angulation. MATERIALS AND METHODS: Eighty subjects (35 with clinically confirmed idiopathic normal pressure hydrocephalus and 45 age- and sex-matched healthy controls) were prospectively enrolled in a 3T brain MR imaging study. Two independent readers assessed 12 radiologic idiopathic normal pressure hydrocephalus biomarkers on sections aligned parallel or perpendicular to the bicallosal, bicommissural, hypophysis-fastigium, and brain stem vertical lines, respectively. RESULTS: Disproportionately enlarged subarachnoid space hydrocephalus, simplified callosal angle, frontal horn diameter, z-Evans Index, and cella media vertical width did not show significant systematic differences in any of 6 section plane combinations studied. The remaining 7 biomarkers (including the Evans Index and callosal angle) showed significant differences in up to 4 of 6 mutually compared section plane combinations. The values obtained from sections aligned with the brain stem vertical line (parallel to the posterior brain stem margin) showed the most deviating results from other section angulations. CONCLUSIONS: Seven of 12 idiopathic normal pressure hydrocephalus biomarkers including the frequently used Evans Index and callosal angle showed statistically significant deviations when measured on sections whose angulations differed or did not comply with the proper section definition published in the original literature. Strict adherence to the methodology of idiopathic normal pressure hydrocephalus biomarker assessment is, therefore, essential to avoid an incorrect diagnosis. Increased radiologic and clinical attention should be paid to the biomarkers showing low angulation-related variability yet high specificity for idiopathic normal pressure hydrocephalus-related morphologic changes such as the z-Evans Index, frontal horn diameter, or disproportionately enlarged subarachnoid space hydrocephalus.

The Benefits of High Relaxivity for Brain Tumor Imaging: Results of a Multicenter Intraindividual Crossover Comparison of Gadobenate Dimeglumine with Gadoterate Meglumine (The BENEFIT Study).

BACKGROUND AND PURPOSE: Gadobenate dimeglumine (MultiHance) has higher r1 relaxivity than gadoterate meglumine (Dotarem) which may permit the use of lower doses for MR imaging applications. Our aim was to compare 0.1- and 0.05-mmol/kg body weight gadobenate with 0.1-mmol/kg body weight gadoterate for MR imaging assessment of brain tumors. MATERIALS AND METHODS: We performed crossover, intraindividual comparison of 0.1-mmol/kg gadobenate with 0.1-mmol/kg gadoterate (Arm 1) and 0.05-mmol/kg gadobenate with 0.1-mmol/kg gadoterate (Arm 2). Adult patients with suspected or known brain tumors were randomized to Arm 1 (70 patients) or Arm 2 (107 patients) and underwent 2 identical examinations at 1.5 T. The agents were injected in randomized-sequence order, and the 2 examinations were separated by 2-14 days. MR imaging scanners, imaging sequences (T1-weighted spin-echo and T1-weighted high-resolution gradient-echo), and acquisition timing were identical for the 2 examinations. Three blinded readers evaluated images for diagnostic information (degree of definition of lesion extent, lesion border delineation, visualization of lesion internal morphology, contrast enhancement) and quantitatively for percentage lesion enhancement and lesion-to-background ratio. Safety assessments were performed. RESULTS: In Arm 1, a highly significant superiority (P < .002) of 0.1-mmol/kg gadobenate was demonstrated by all readers for all end points. In Arm 2, no significant differences (P > .1) were observed for any reader and any end point, with the exception of percentage enhancement for reader 2 (P < .05) in favor of 0.05-mmol/kg gadobenate. Study agent-related adverse events were reported by 2/169 (1.2%) patients after gadobenate and by 5/175 (2.9%) patients after gadoterate. CONCLUSIONS: Significantly superior morphologic information and contrast enhancement are demonstrated on brain MR imaging with 0.1-mmol/kg gadobenate compared with 0.1-mmol/kg gadoterate. No meaningful differences were recorded between 0.05-mmol/kg gadobenate and 0.1-mmol/kg gadoterate.

Are there differences between macrocyclic gadolinium contrast agents for brain tumor imaging? Results of a multicenter intraindividual crossover comparison of gadobutrol with gadoteridol (the TRUTH study).

BACKGROUND AND PURPOSE: Gadobutrol (Gadavist) and gadoteridol (ProHance) have similar macrocyclic molecular structures, but gadobutrol is formulated at a 2-fold higher (1 mol/L versus 0.5 mol/L) concentration. We sought to determine whether this difference impacts morphologic contrast-enhanced MR imaging. MATERIALS AND METHODS: Two hundred twenty-nine adult patients with suspected or known brain tumors underwent two 1.5T MR imaging examinations with gadoteridol or gadobutrol administered in randomized order at a dose of 0.1 mmol/kg of body weight. Imaging sequences and T1 postinjection timing were identical for both examinations. Three blinded readers evaluated images qualitatively and quantitatively for lesion detection and for accuracy in characterization of histologically confirmed brain tumors. Data were analyzed by using the Wilcoxon signed rank test, the McNemar test, and a mixed model. RESULTS: Two hundred nine patients successfully completed both examinations. No reader noted a significant qualitative or quantitative difference in lesion enhancement, extent, delineation, or internal morphology (P values = .69-1.00). One hundred thirty-nine patients had at least 1 histologically confirmed brain lesion. Two readers found no difference in the detection of patients with lesions (133/139 versus 135/139, P = .317; 137/139 versus 136/139, P = .564), while 1 reader found minimal differences in favor of gadoteridol (136/139 versus 132/139, P = .046). Similar findings were noted for the number of lesions detected and characterization of tumors (malignant/benign). Three-reader agreement for characterization was similar for gadobutrol (66.4% [κ = 0.43]) versus gadoteridol (70.3% [κ = 0.45]). There were no significant differences in the incidence of adverse events (P = .199). CONCLUSIONS: Gadoteridol and gadobutrol at 0.1 mmol/kg of body weight provide similar information for visualization and diagnosis of brain lesions. The 2-fold higher gadolinium concentration of gadobutrol provides no benefit for routine morphologic imaging.

MRI-based pre-planning in patients with cervical cancer treated with three-dimensional brachytherapy.

OBJECTIVE: The aim of this study was to analyse the feasibility and determine the benefits of MRI-based pre-planning with CT/MRI data fusion in patients with cervical cancer treated with radical radiotherapy. METHODS: Patients underwent MRI examination prior to external beam radiotherapy and prior to the first and fourth fraction of brachytherapy with applicators in place. Insertion of applicators at the radiology department was performed under paracervical anaesthesia. The benefit of MRI pre-planning was determined by comparing conventional treatment planning with dose specification to "point A" and dose specification to 90% of the high-risk clinical target volume (HR-CTV D90). Tolerance of MRI evaluation with applicators, coverage of HR-CTV and dose-volume parameters for organs at risk (OAR) has been assessed in 42 brachytherapy procedures. RESULTS: Insertion of applicators at the radiology department was successful in all patients and there were no complications. The target dose was higher for MRI planning than for conventional planning (5.3 Gy vs 4.5 Gy). Maximum doses in the bladder and rectum were significantly lower (p<0.05) for MRI planning than for the conventional approach (6.49 Gy vs 7.45 Gy for bladder; 4.57 Gy vs 5.06 Gy for rectum). We found no correlation between the International Commission on Radiation Units (ICRU) point dose for OAR and the maximum dose in OAR. Nevertheless, a strong correlation between the maximum dose in OAR and the minimal dose in a volume of 2 cm(3) has been observed. CONCLUSION: MRI-based pre-planning with consecutive CT/MRI data fusion is feasible and safe, with the advantage of increasing the dose to the tumour and decreasing the dose to the organs at risk.

Cytokine expression in cord blood cells of children of healthy and allergic mothers.

To determine some early signs connected with the increased risk of future allergy development, gene expression and production of selected cytokines were tested in children of allergic mothers and compared with newborns of healthy mothers. Expression of IL-1ß, IL-2, IL-4, IL-8, IL-10, IL-13, IFN-γ, TNF-α, TGF-ß and EGF was tested in cord blood cells using real-time PCR and production of these cytokines was evaluated in cord sera by ELISA. Gene expression of IL-2, IL-4, IL-8, IFN-γ, IL-1ß, TNF-α and TGF-ß was decreased and that of IL-10, IL-13 and EGF increased in children of allergic mothers in comparison with those of healthy mothers. Significant differences in sera of healthy and allergic groups were only in IL-10 and EGF. Different relationship among serum cytokine levels reflects the fact that the cytokines are not produced only by blood cells. Significantly decreased production of EGF in newborns of allergic mothers could negatively influence maturation of mucosal membranes of these children and support thus their easier allergization. Allergic phenotype pointing to the bias to T(H)2 response and to possibly impaired intestine maturation was apparent already on the level of cord blood and could serve as a predictive sign of increased allergy risk.

[Evaluation of cardiovascular high risk population in specialist ambulatory care: ESA]. / Evaluation of cardiovascular high risk population in Specialists Ambulance: ESA.

BACKGROUND: Arterial hypertension is the most common CV disease in the Czech Republic with estimated prevalence 35% among population aged 25 to 64 years. Although serious public health problem with significant medical and economic consequences the treatment of HT is currently unsatisfactory. Only 18.4% of patients with arterial HT reach goal BP. There are several factors responsible for this fact, among them low compliance of patients, low dosages of antihypertensive drugs used and low usage of the combination of antihypertensive drugs. AIM: To obtain following data from the specialists ambulances (internists and cardiologists) regarding hypertensive patients: frequency of high risk hypertensive patients and proportion of patients with hypertension in whom BP is well controlled (target BP reached). Another goal of the study was to obtain data about pharmacological treatment of hypertensive patients. METHOD: National, multicenter, non-interventional, cross sectional, representative sample, one visit study. RESULTS: Data of 19,821 patients with primary hypertension visited office-based internists and cardiologists was analysed. The average age was 64 +/- 12 years (range 19-99 years), 53% was women. The mean blood pressure of entire population was 138.5 +/- 15.1/81.7 +/- 9.1 mm Hg. There were high proportion of patients with well controlled blood pressure (BP below 140/90 mm Hg)--48% of the patients. Among those with diabetes the proportion of well controlled patients was much lower--only 11% of the patients. Regarding other cardiovascular risk factors the most common was hyperlipidaemia--66% of the patients, following by diabetes and smoking with 29 and 14% of the patients respectively. 8,444 (43%) of the patients suffered from the coronary artery diseases, 2,251 (11%) patients have experienced stroke or TIA and 1,601 (8%) patients had peripheral artery disease. Regarding antihypertensive therapy, only 21% of the population was treated by monotherapy. The most common was the combination of ACE inhibitors plus beta-blockers or triple-combination of ACE inhibitors plus diuretics plus beta-blockers.

Neurovascular compression: sympathetic activity in severe arterial hypertension.

Compression of the rostral ventrolateral medulla oblongata (RVLM) by an abnormally located artery is regarded as one possible cause of arterial hypertension. There exists a limited set of data suggesting that increased sympathetic activity in patients with RVLM compression may lead to arterial hypertension. Accordingly, we decided to assess the sympathetic activity in patients with severe arterial hypertension and to investigate any correlation with the presence of RVLM compression. Sixty-four patients with severe arterial hypertension were enrolled in our study. Sympathetic activity was evaluated using 24-hour urinary norepinephrine as measured by high-pressure liquid chromatography with electrochemical detection. The presence of RVLM compression was assessed with magnetic resonance imaging. Neurovascular compression of the RVLM was identified in 40 patients, 27 of whom presented left-sided compression. Twenty-four hour urinary norepinephrine averaged 263.6+/-135.9 nmol in patients with neurovascular compression - 255.6+/-137.3 nmol in those with left-sided compression and 251.6+/-138.5 nmol in patients without RVLM compression. We did not identify any increase in urinary norepinephrine in patients with severe arterial hypertension and neurovascular compression of the RVLM. Our results do not support the hypothesis that neurovascular compression of RVLM may exhibit a sympathetically mediated increase in blood pressure.

IgE against food and respiratory allergens in healthy and allergic mothers and their children.

IgE against mixtures of common food or respiratory allergens were determined by ELISA in healthy (n = 38) and allergic (n = 62) mothers and their children. Significantly higher level of IgE against respiratory allergens was found in sera of allergic mothers and in cord blood of their children. No correlation between antibody level in maternal and newborn's sera was found; this argues against the transfer of IgE from mother to fetus and points rather to offspring's intrauterine sensitization. Specific IgE level in cord blood was higher in children who developed later allergy than in children who did not. Specific IgE level in colostrum was low both in healthy and allergic mothers; there was no correlation between high concentration of IgE against respiratory allergens in sera of allergic mothers and their colostrum, which does not support the idea of IgE transport from blood to mammary gland. Only slightly increased colostral IgE was detected in allergic mothers whose children manifested allergy later. Allergy of the mother and high level of anti-allergen IgE in her serum and in cord blood are the main predictive factors of future occurrence of allergy in the offspring. A combination of several predictive factors could have higher prognostic value.

[Current use of magnetic resonance imaging in cardiology]. / Soucasné moznosti zobrazení magnetickou rezonancí v kardiologii.

Magnetic resonance imaging is a modern imaging technique that is characterized by high resolution and variable tomographic slices. The development of magnetic resonance technology in last decade led to the expansion of this method in many fields of medicine. In cardiology, the imaging is focused on the heart, aorta, pulmonary, coronary and renal arteries. Dynamic imaging is used for the evaluation of the kinetics and the function of the ventricles. Static imaging serves for the assessment of the myocardial wall in patients with cardiomyopathies and coronary artery disease. The quality of static imaging can improve paramagnetic contrast agent that increasingly accumulates in areas of acute necrosis, fibrosis or infiltration of the myocardium. Magnetic resonance imaging can also diagnose intracardiac tumors and thrombi, valvular heart disease and pericardial disorders. Despite of wide spectrum of diagnostic applications, the clinical use of magnetic resonance imaging is reduced by limited availability and high cost of the examination.

Effect of oral application of a probiotic E. coli strain on the intestinal microflora of children of allergic mothers during the first year of life.

Influence of intestinal colonization by a probiotic E. coli strain on the incidence of bacterial pathogens in stool and allergic symptoms during the 1st year of life was monitored in 3 groups: colonized children of allergic mothers (AC; n = 52), noncolonized children of allergic mothers (AN; n = 50), children of nonallergic mothers (NC; n = 42). Colinfant vaccine was administered within 2 d after birth, 3 x a week over a period of 4 weeks. Stool samples were examined after 2 d and at the age of 3, 6 and 12 months. At 3 months E. coli was present in 90 %, at 12 months in 73 % of AC. Pathogens were significantly less frequent on day 3 and at 3 months in AC vs. AN (15 vs. 61 %, p < 0.001; 15 vs. 38 %, p < 0.01) and vs. NC (15 vs. 63 %, p < 0.001; 15 vs. 53 %, p < 0.001). AC exhibited lower incidence of Staphylococcus epidermidis than AN on day 3 (6 vs. 31 %, p < 0.001) and of Klebsiella strains on day 3 and at 3 months (4 vs. 20 %, p < 0.05; 5 vs. 24 %, p < 0.01). AC showed a lower incidence of Pseudomonas aeruginosa than NC on day 3 (6 vs. 31 %, p < 0.01) and Klebsiella spp. on day 3 and at 3 months (4 vs. 22 %, p < 0.05; 5 vs. 45 %, p < 0.001). No significant differences were recorded after 6 and 12 months. The incidence of allergies was 3 % in AC, 26 % in AN (p < 0.01), and 10 % in NC.

Perinatal period cytokines related to increased risk of future allergy development.

Testing of cytokine levels in colostrum, cord blood and amniotic fluid of healthy and allergic mothers and their newborns (using protein microarrays and quantitative analysis by ELISA) revealed differences in the levels of IL-5, IL-10, TGF-beta, TNF-alpha, EGF and eotaxin between healthy and allergic groups. Significantly higher concentration of IL-5 and IL-10 in the colostrum of allergic mothers and cord blood of their children and also tendency to a higher level of IL-4 found at allergic mothers and their children (but without statistical significance) indicate a bias to T(H)2 response in this group. The higher level of TGF-beta in the colostrum of healthy mothers should be involved in beneficial immunological tuning of their children including enhanced IgA formation and better intestine maturation. In amniotic fluid, concentration of TGF-beta was higher in children of allergic mothers. A significantly higher level of EGF was proved in the colostrum of healthy mothers and in cord blood of their children in comparison with allergic group. EGF deficiency in the allergic group could impair or delay intestine maturation and support thus allergy development.

[Prenatal detection of congenital mezoblastic nephroma]. / Prenatální záchyt kongenitálního mezoblastického nefromu.

TYPE OF STUDY: Case report. SETTING: Department of Gynecology and Obstetrics, Department of Radiology, Department of Pathology, Department of Medical Genetics, Charles University Hospital, Hradec Králové. METHODS: The autors report a case of renal tumor in a fetus at 33 weeks of gestation detected by means of ultrasonography and magnetic resonance imaging. The pregnancy course was complicated by polyhydramnios. The female infant was born vaginally at 37 weeks of gestation. Postnatal nephrectomy confirmed prenatal diagnostic presumption - congenital mezoblastic nephroma. At follow-up at 12 months of age, the infant had no evidence of the disease. CONCLUSION: Detection of renal tumor in a fetus is rare. Congenital mezoblastic nephroma with the favourable prognosis is most probable diagnosis. Prenatal detection enables the prevention of complications (prematurity prevention, detection of the developing cardial decompensation and fetal hydrops) with the planning of labour and postnatal management.

Complete response of multiple melanoma brain metastases after treatment with temozolomide.

BACKGROUND: Inoperable melanoma brain metastases are usually uniformly fatal, and complete response after cytotoxic therapy is rare. CASE REPORT: A patient with multiple inoperable melanoma brain metastases was treated with 6 cycles of oral temozolomide (300 mg once daily over 5 days every 28 days). A complete response was documented by magnetic resonance. CONCLUSIONS: The present observation suggests that temozolomide may be an active and well tolerated treatment for malignant melanoma brain metastases.

[Influence of oral colonization with probiotic E. coli strain after birth on frequency of recurrent infections, allergy and development of some immunologic parameters. Long-term studies]. / Vliv perorálního osídlení probiotickým kmenem E.coli po narození na výskyt opakovaných infekcí, alergií a vývoj nekterých imunologických ukazatelu. Výsledky dlouhodobého sledování.

OBJECTIVE: prevention of repeated infections and allergies in children of allergic mothers by oral colonization with probiotic E. coli strain.The development of some immunologic parameters. Long - term studies. DESIGN: Original contribution SETTING: Mother and Child Care Institute of Prague. METHODS AND RESULTS: The results of our long-term studies confirmed that orally administered probiotic E. coli strain after birth rapidly colonized the gastrontestinal tract of the newborn and remained dominant for many weeks. The long-term presence of the strain in the intestine stimulated local and serum antibody response. Early induction of secretory IgA production is important particularly in formula-fed infants. The long-term presence of the E. coli strain in the intestine decreased the numer of pathogens colonizing intestinal and other mucous membranes , the frequency of infections and reduced need for antibiotics in premature and high-risk infants. Ten years later, there was still a lower frequency of repeated infections (23%) in comparison with control children (58%). Colonization with probiotic E. coli strain in infants treated in protected (pathogen-free) environment represented effective prevention of nosocomial infections In the colonized group infections occured in 16% of infants and 130 isolates and 7 genera of pathogens were demonstrated. In the group treated in conventional environment 40% of infants had nosocomial infections, 238 isolates and 10 genera of pathogens were proved. The hospitalization period was shorter in the first group (26 versus 34 days). Intentional colonization with probiotic E. coli after birth reduced incidence of allergies after 10 and 20 years (being 12% and 16% in the colonized groups and 33 and 32% in controls). In the present long - term study (evaluated after the first year) colonization with vaccine COLINFANT after birth influenced the levels of some cytokines ( IL-4, IFN-gama,TGF-beta) and also clinical manifestation of allergy (there were no signs of allergy in colonized infants of allergic mothers, but 25% of infants of control allergic mothers had clinical manifestations of allergies). CONCLUSIONS: By replacement of the natural but incidental ( event. pathogenic ) colonization of the intestine by a targeted orally administered E. coli strain after birth we may have come upon the possibility of how to prevent nosomial infections particularly in formula-fed and high-risk infants and prevent occurence of allergies in infants of allergic mothers.

Currarino triad: concurrent US and MRI diagnosis in the fetus and the mother.

We report an unusual case of the complete Currarino triad diagnosed in a fetus at 21 weeks' gestation by means of prenatal ultrasonography (US). The highly suspicious findings in the fetus were accompanied by analogous US findings in the mother who suffered from mild symptoms of up to that time unrecognized Currarino triad. Consecutively, magnetic resonance imaging (MRI) confirmed the findings simultaneously in the fetus and in her mother. This is the first report describing the prenatal diagnosis of Currarino triad without the background of positive family history. To our knowledge, the prenatal MRI findings of Currarino triad have not yet been published.

[Magnetic resonance in urogynecology]. / Vyuzití magnetické rezonance v urogynekologii.

OBJECTIVE: The aim of the study was to review the use of the MRI in urogynaecology and to describe an original method for the construction of 3D computer models of pelvic floor. DESIGN: Pilot study. SETTING: Department of Obstetrics and Gynaecology, Institute of Sexuology, 1st Faculty of Medicine, Charles University, Prague, Department of Radiodiagnostics, Charles University, Hradec Králové. METHODS: A review of the use of the MRI in urogynaecology was made. A new method was introduced for creation of computer 3D models of female pelvis based on the data obtained by the MRI. RESULTS: Five complex computer models of the female pelvic organs and pelvic floor were created. Many so far estimated details were visualized. CONCLUSION: The use of MRI in urogynaecology can bring important data about the functional anatomy of female pelvic floor.

Extensive spinal epidural hematoma: a rare complication of aortic coarctation.

Development of collateral circulation belongs among the typical signs of aortic coarctation. Cerebral or spinal artery aneurysm formation with increased risk of subarachnoid hemorrhage represent the most common neurovascular complication of this disease. We report a case of a 20-year-old sportsman who developed acute non-traumatic paraplegia as a result of extensive spinal epidural hemorrhage from collateral vessels accompanying aortic coarctation which was unrecognized up to that time. To the best of our knowledge, acute spinal epidural hematoma as a complication of aortic coarctation has not been previously reported.

Paraplegia as an unusual manifestation of aortic coarctation.

In this report, we present an unusual case of a 20-year-old man whose first symptom of aortic coarctation was sudden paraplegia due to spinal epidural hemorrhage caused by rupture of an aneurysmal collateral vessel. Now, one year after surgical correction of coarctation, the patient has had no cardiac or neurological problems. To our knowledge, this is the only clearly documented case of such an aortic coarctation complication.