Long survival of primary diffuse leptomeningeal gliomatosis following radiotherapy and temozolomide: case report and literature review

Objective

Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare neoplasm with a short survival time of a few months. there is currently no standardized therapeutic approach for PDLG.

Materials and methods

We report on a 53-year-old male patient who presented with epileptic seizures, gait disturbance, paraparesis and sensory deficits in the dermatomes T8-10.

Results

Magnetic resonance imaging (MRI) revealing numerous spinal and cranial gadolinium-enhancing nodules in the meninges and histopathology led us to diagnose primary diffuse leptomeningeal gliomatosis with WHO grade III astrocytic cells. Consecutively, the patient underwent craniospinal radiotherapy (30 Gy) and 11 sequential cycles of temozolomide. This regimen led to partial tumor regression. Thirteen months later, spinal MRI revealed tumor progression. Second-line chemotherapy with 5 cycles of irinotecan and bevacizumab did not prevent further clinical deterioration. The patient died twenty-two months after diagnosis, being the longest survival time described thus far with respect to PDLG consisting of astrocytic tumor cells.

Conclusions

Radiochemotherapy including temozolomide, as established standard therapy for brain malignant astrocytomas, might be valid as a basic therapeutic strategy for this PDLG subtype.     

Lumbar radiculopathy caused by foraminal stenosis in rheumatoid arthritis

Study design

Case-series study.

Objective

To describe the clinical presentation, characteristic findings of imaging studies, and treatment of lumbar radiculopathy caused by foraminal stenosis in rheumatoid arthritis.

Background

Lumbar lesions in rheumatoid arthritis are relatively rare, with a limited number of systemic reports.

Methods

Six patients with lumbar radiculopathy caused by foraminal stenosis in rheumatoid arthritis were treated. The patients were all women with a mean age of 69 years and mean rheumatoid arthritis duration of 15 years. The medical records and imaging studies of all patients were reviewed.

Results

The affected nerve roots were L4 in four patients and L3 in two patients. Foraminal stenosis was not demonstrated in magnetic resonance images in four of the six patients. Selective radiculography with nerve root block reproduced pain, manifested blocking effect, and demonstrated compression of the nerve root by the superior articular process of the lower vertebra in all patients. Conservative treatment was performed on one patient, and surgery was conducted for the rest of the five patients; radiculopathy was improved in all patients.

Conclusions

Lumbar foraminal stenosis is a characteristic pathology of rheumatoid arthritis, and should be kept in mind in the diagnosis of lumbar radiculopathy. Selective radiculography is useful in the diagnosis of affected nerve roots.     

Magnetic Resonance Imaging in Evaluation of Periventricular Leukomalacia

Background

Improvements in perinatal care have resulted in increased survival of infants born prematurely, however neurological damage due to ischaemic infarction of the periventricular white matter is a problem of enormous medical, social and economic importance. Such vascular insult leads to destruction of the periventricular white matter, termed periventricular leukomalacia (PVL). This abnormality is the leading cause of significant morbidity in the survivors of premature birth. Magnetic Resonance Imaging (MRI) is perhaps the only imaging modality, which can accurately detect and quantify periventricular leukomalacia. Methods: Magnetic Resonance Imaging was carried out in 45 children in the age group of 4 weeks to 8 years, with history of premature birth and perinatal hypoxia. These children had neurological deficits ranging from cortical blindness, spastic diplegia, spastic quadriplegia to severe mental retardation. The procedure was carried out on a 1.5 Tesla (Siemens Magnetom Avanto) MR system using available protocols for imaging the paediatric brain.

Result

The study revealed that MR imaging could accurately identify areas of ischaemic infarction of the periventricular white matter both in the early as well as in the late stages. The pattern of abnormalities detected on MRI of the brain in these patients can be considered specific for PVL in the clinical background of premature birth and perinatal hypoxia.

Conclusion

MRI is the ideal imaging modality to detect, quantify and accurately map the areas of brain affected by this hypoxic-ischaemic process. It is presently the gold standard for evaluating the neuroparenchyma in those with perinatal hypoxia. Advanced MR techniques like Diffusion Weighted Imaging (DWI), Proton MR Spectroscopy and DTI have shown great promise in our understanding of the pathophysiology and anatomic considerations of this disease process.Key Words: Hypoxic ischaemic encephalopathy, Magnetic resonance imaging, Periventricular leukomalacia     

MR urography: Anatomical and quantitative information on congenital malformations in children

Background and Aim:

Magnetic resonance urography (MRU) is considered to be the next step in uroradiology. This technique combines superb anatomical images and functional information in a single test. In this article, we aim to present the topic of MRU in children and how it has been implemented in Northern Greece so far. The purpose of this study is to demonstrate the potential of MRU in clinical practice. We focus both on the anatomical and the quantitative information this technique can offer.

Materials and Methods:

MRU was applied in 25 children (ages from 3 to 11 years) diagnosed with different types of congenital malformations. T1 and T2 images were obtained for all patients. Dynamic, contrast-enhanced data were processed and signal intensity versus time curves were created for all patients from regions of interest (ROIs) selected around the kidneys in order to yield quantitative information regarding the kidneys function.

Results:

From the slopes of these curves we were able to evaluate which kidneys were functional and from the corticomedullary cross-over point to determine whether the renal system was obstructed or not.

Conclusion:

In all 25 cases MRU was sufficient, if not superior to other imaging modalities, to establish a complete diagnosis.     

Twenty-seven years follow-up of a patient with congenital retinocephalofacial vascular malformation syndrome and additional congenital malformations (Bonnet-Dechaume-Blanc syndrome or Wyburn-Mason syndrome)

Purpose

Follow-up of vascular changes in a patient with congenital retinocephalofacial vascular malformation syndrome.

Methods

MRI and cerebral angiography.

Results

In a 36-year-old man, magnetic resonance im aging of the skull and cerebral angiography revealed left intracranial arteriovenous malformations. Follow-up observation of 27 years revealed no essential change of retinal and cerebral arteriovenous malformations. Additional congenital deficits in this patient were described.

Conclusion

Patients with retinal arteriovenous malformations should be early examined with neuroradiological methods.     

Valuable Radiographic Tool for Odontogenic Jaw Keratocyst Diagnosis and Surgical Planning

Objective:

To investigate the clinical use of cone beam computed tomography in the diagnosis of patients with odontogenic jaw keratocyst and to guide computer-aided surgical treatment planning.

Methods:

Imaging, image processing, and visualization technologies were used to produce clear diagnosis, provide proper treatment, and formulate favourable prognosis. Cone beam computed tomography was used to collect medical information including site, extent, shape, and other characteristic features of a patient with large odontogenic jaw keratocyst.

Results:

The imaging technique produced excellent results in imaging, image processing and threedimensional (3D) visualization.

Conclusion:

The 3D digital reconstruction model of the odontogenic jaw keratocyst was shown intuitively.     

Diffusion weighted magnetic resonance imaging for acute stroke: practical and popular

Aim

To evaluate the feasibility and impact of diffusion weighted magnetic resonance imaging (DW MRI) as the first line neuroimaging of stroke at a district general hospital.

Methods

Prospective audit of all in‐patients admitted with clinically suspected acute stroke and referred for imaging over a consecutive 17 week period. The data collected included scan type, time from cerebral event to imaging request, and time from formal radiological request to neuroimaging. Clinicians'' (general physicians, neurologists, and radiologists) perceptions were assessed by a questionnaire.

Results

148 patients had neuroimaging for clinically suspected stroke during this period. Eighty one per cent of patients (120 of 148) had DW MRI as first line. Ninety two per cent of these patients had DW MRI within 24 hours of the formal radiological request. Twenty eight patients did not undergo DW MRI because lack of MRI safety, clinical state, unavailability because of maintenance service or lack of trained staff. Clinicians found the introduction of the DW MRI based service a significant improvement on computed tomography, especially for equivocal cases.

Conclusion

DW based MRI service is both feasible and sustainable in the setting of a district general hospital and most clinicians feel that this is a significant improvement to stroke services.     

Spiral CT Angiography: Applications in Neurovascular Imaging

Background

The advent of Spiral Computed Tomographic (CT) angiography has provided the patients a non-invasive, accurate and fast modality of imaging the vasculature.

Methods

Spiral CT angiography was performed in 30 patients to evaluate intracranial circulation using standard protocols of data acquisition. The images were processed and reconstructed in 3-dimension to delineate anatomy and pathology accurately.

Results

The study established that CT angiography is an accurate modality for evaluating the intracranial circulation in a variety of abnormalities. It is safe both in terms of being non-invasive and exposure to radiation. It has a distinct advantage over other non-invasive modalities of imaging like MRI in the evaluation of patients with metallic stents and clips.

Conclusion

CT angiography has tremendous potential in imaging the intracranial vasculature. It is unquestionably safer than catheter angiography as it avoids arterial puncture and intra-arterial catheter manipulation. It is fast and capable of producing excellent 3-dimensional images of the intracranial vasculature.Key Words: Neurovascular imaging, Spiral CT, CT Angiography     

Comparison of guideline recommendations with daily practice in patients with renal cell carcinoma

Objectives and Aims

To compare guideline recommendations with daily practice patterns in a German patient cohort with renal cell carcinoma.

Patients and methods

81 patients with T1 oder T2 renal cell carcinoma (RCC) were included in this prospective single-center study. All patients were operated in a single institution either by open radical nephrectomy (ORN) or nephron sparing surgery (NSS). Patients and doctors were evaluated using a written questionnaire with a follow-up of 12 months. Follow-up intervals, follow-up modalities (e. g. imaging modalities, laboratory controls of blood and urine) and the call on psycho-oncological support were evaluated.

Results

The majority of patients (72%) were followed up by their urologists. Follow-up examinations included abdominal ultrasound, urine and blood diagnostics, conventional chest x-rays, computed tomography (CT) of abdomen, chest or head or abdominal Magnetic Resonance Imaging (MRI). There were no significant differences between patients operated by ORN or NSS. In total, 12.5% of patients were asking for psycho-oncological support.

Conclusions

In general, patients were followed up according to existing guideline recommendations. Only a small proportion of patients asked for psycho-oncological treatment.     

Anaesthesia for Paediatric Cardiac MRI

Background

General anaesthesia (GA) for cardiac magnetic resonance imaging (MRI) in patients with congenital heart disease (CHD) is challenging for the anaesthesiologist.

Methods

A retrospective review of anaesthesia for cardiac MRI between January 2002 and December 2005 was undertaken.

Result

28 children with cardiac disease were subjected to general anaesthesia for cardiac MRI, of which four patients were in ASA Grade I, five in Grade II, seventeen in Grade III and two in Grade IV. Two patients had undergone previous cardiac surgery. All the cases were managed as inpatients, of which 18 had cyanotic cardiac defects (SpO₂ between 65 and 85%). On two occasions scans were interrupted because of low oxygen saturation or haemodynamic instability during GA. No patient was admitted to the hospital for complications related to general anaesthesia though all were kept under observation for two hours before being shifted to ward. Five patients had a brief episode of hypotension/desaturation during the MRI and responded quickly to interventions.

Conclusion

General anaesthesia for cardiac MRI can be administered safely in children with CHD.Key Words: Cardiac MRI, Congenital heart defects, General anaesthesia     

Can fruit seeds and undigested plant residuals cause acute appendicitis

Objective

To investigate the relation between fruit seeds, plants residuals and appendicitis.

Methods

Among cases that underwent appendectomy, the appendicitis cases having fruit seeds and undigested plant residuals in their etiology were examined retrospectively. Also, histopathological features, age, sex, and parameters of morbidity and mortality were used.

Results

Fruit seed was found in one case (0.05%) with presence of pus in appendix lumen, undigested plant residuals in 7 cases (0.35%). It was determined that there were appendix inflammation in 2 of the plant residuals cases, while there were obstruction and lymphoid hyperplasia in the appendix lumen of 5 cases. No mortality was observed.

Conclusions

The ratio of acute appendicitis caused by plants is minimal among all appendectomised patients, but avoidence of eating undigested fruit seeds and chewing plants well may help to prevent appendicitis.     

External Versus Endoscopic Dacryocystorhinostomy: A Retrospective Study

Background

External dacryocystorhinostomy (DCR) has been the standard surgery for nasolacrimal duct obstruction before the development of endoscopic DCR.

Methods

This retrospective study included 103 patients with 109 cases (6 cases with bilateral disease) of nasolacrimal duct obstruction, of which 55 were treated with external DCR and 54 with endoscopic DCR. They were followed up for a minimum period of six months for surgical outcome.

Result

The mean age of the patients in both the groups was 30 years. The success rate defined as absence of epiphora in the external DCR group was 90.9% and 95 % in the endoscopic DCR group. Majority of the recurrence, 5 out of the 6 (83.3%) in the external DCR group occurred in the first two months of surgery, while one reported four months after the surgery. The problem of intraoperative hemorrhage encountered in the external DCR group was not faced in the endoscopic DCR group. Revision of DCR was indicated in 9.1 % of cases in external DCR group as compared to 5.5 % in the endoscopic group. Serious complications like keloid formation and cosmetically unacceptable scar were not noticed in the external DCR group. Cerebrospinal fluid (CSF) rhinorrhoea was not encountered in the endoscopic group.

Conclusion

Both the external DCR and the endoscopic DCR are effective surgical approaches for nasolacrimal duct obstruction with comparable success rate.Key Words: External dacryocystorhinostomy, Endoscopic dacryocystorhinostomy     

Patient-controlled sharing of medical imaging data across unaffiliated healthcare organizations

Background

Current image sharing is carried out by manual transportation of CDs by patients or organization-coordinated sharing networks. The former places a significant burden on patients and providers. The latter faces challenges to patient privacy.

Objective

To allow healthcare providers efficient access to medical imaging data acquired at other unaffiliated healthcare facilities while ensuring strong protection of patient privacy and minimizing burden on patients, providers, and the information technology infrastructure.

Methods

An image sharing framework is described that involves patients as an integral part of, and with full control of, the image sharing process. Central to this framework is the Patient Controlled Access-key REgistry (PCARE) which manages the access keys issued by image source facilities. When digitally signed by patients, the access keys are used by any requesting facility to retrieve the associated imaging data from the source facility. A centralized patient portal, called a PCARE patient control portal, allows patients to manage all the access keys in PCARE.

Results

A prototype of the PCARE framework has been developed by extending open-source technology. The results for feasibility, performance, and user assessments are encouraging and demonstrate the benefits of patient-controlled image sharing.

Discussion

The PCARE framework is effective in many important clinical cases of image sharing and can be used to integrate organization-coordinated sharing networks. The same framework can also be used to realize a longitudinal virtual electronic health record.

Conclusion

The PCARE framework allows prior imaging data to be shared among unaffiliated healthcare facilities while protecting patient privacy with minimal burden on patients, providers, and infrastructure. A prototype has been implemented to demonstrate the feasibility and benefits of this approach.     

Comparative analysis of changes in MR imaging of pre and post intrauterine progesterone implants in adenomyosis cases

Background

Magnetic Resonance Imaging (MRI) plays an important role in the evaluation and management of adenomyosis. In this study, we first diagnosed the adenomyosis on MRI and then we analyzed the MRI changes in the uterus in pre and post intrauterine progesterone implants cases.

Method

All the patients with clinical diagnosis of menorrhagia or dysmenorrhea were screened by Ultrasonography (USG) of the pelvis. Patients with heterogeneous echo texture of the uterus were then evaluated by the MRI of the pelvis. All patients with MRI findings suggestive of adenomyosis formed the study group.

Result

On MRI study 60 patients were diagnosed as adenomyosis, 68.33% had diffuse adenomyosis and 31.66% had focal adenomyosis. 83% of diagnosed adenomyosis cases had high intensity signal foci which were seen in 75% cases of diffuse adenomyosis and 100% cases of focal adenomyosis. 50 diagnosed adenomyosis cases were then reviewed after 03 months, 06 months and 12 months to see for any change in the MRI findings in the post intrauterine implant cases. On follow up MRI after post progesterone intrauterine implant, 50% of the cases showed reduction in the high intensity signals, 10% of the cases showed mild reduction in the junctional zone thickness with no significant change in the uterine size.

Conclusions

It is inferred that MR imaging is not only helpful in diagnosing but also helpful in monitoring the effects of hormonal therapy in adenomyosis.     

Factors related to successful outcome of conservative treatment for rotator cuff tears

Background

Much controversy exists as to the management of full-thickness tears of the rotator cuff. Not all patients with rotator cuff tears require surgical treatment. We have little information whether there are factors that are related to successful outcome of conservative treatment.

Aim

The purpose of this study was to determine the factors related to the successful outcome following conservative treatment.

Methods

This study included 123 shoulders in 118 patients with full-thickness tears of the rotator cuff diagnosed by high-resolution magnetic resonance imaging with a microscopy coil. All patients were treated conservatively for at least 3 months. Clinical symptoms improved in 65 shoulders in 62 patients by conservative treatment (conservative group), but remained unchanged or aggravated in 58 shoulders in 56 patients, who eventually underwent surgical repair (surgical group).

Results

The following parameters showed significant differences: 1) integrity of the intramuscular tendon of the supraspinatus (24.1% in the surgical group and 58.4% in the conservative group showed an intact intramuscular tendon); 2) supraspinatus muscle atrophy (occupancy ratio was 69.8% in the surgical group and 78.0% in the conservative group); 3) impingement sign (positive in 79.3% in the surgical group and 30.7% in the conservative group); and 4) external rotation angle (35.0 degrees in the surgical group and 52.2 degrees in the conservative group). The success rate of conservative treatment was 87% in the cases with at least three of these four factors.

Conclusion

These four factors are useful in selecting patients who will respond well to conservative treatment before initiating the treatment.     

Prevalence of patent foramen ovale in a consecutive cohort of 261 patients undergoing routine "coronary" 64-multi-detector cardiac computed tomography

Background

A patent foramen ovale (PFO) is strongly associated with cryptogenic stroke (CS), neurological and other phenomena. The reported prevalence of PFO varies according to the imaging technique used and population studied.

Purpose

To measure prospectively, the prevalence of PFO in a cohort of consecutive patients attending for routine “coronary” CT angiography using standard, everyday coronary protocols including low-dose prospective ECG gated studies.

Methods

Standard coronary imaging protocols were used. PFOs were graded according to the classification of Williamson et al.¹

Results

261 patients were studied. A PFO was identified in 22.6% (11.5% grade 1 (closed flap), 6.5% grade 2 (open flap) and 4.6% grade 3 (open flap with jet)). A further 6.1% had an atrial septal aneurysm.

Conclusions

The prevalence of all grades of PFO (22.6%) and open flap PFO (11.1% = grade 2 and 3) with this technique compares with 24.3% by trans-oesophageal echocardiography (TOE) and 14.9% by saline contrast echocardiography (SCE)^{2, 3} Further comparative studies are required but we believe an open flap PFO or ASA should be identified and recorded during cardiac CT. This approach may identify those at risk of cryptogenic stroke as well as avoid unnecessary tests in stroke patients.     

Three Dimensional Spiral CT Imaging of the Musculoskeletal System: Application and Advantages

Background

Clinical applications of spiral computed tomography (CT) have increased extensively over the past decade and continue to widen rapidly. The introduction of three-dimensional(3-D) reconstruction in CT technology has revolutionized medical imaging. This advancement has been possible due to the combination of spiral computed tomography and various 3-D reconstruction protocols which have permitted rapid and comprehensive examination of all regions of the body. It has unequivocal advantages in the preoperative planning of craniofacial surgery, assessment of complex fractures of the skeletal system especially pelvis and in the surgical treatment of dysplastic hips in children.

Methods

3-D spiral CT imaging of various parts of the musculoskeletal system was carried out in 60 cases using available protocols, at the CT scan center of a large tertiary care service hospital.

Results

The study provided a new approach in the analysis of complex anatomic relationships of the musculoskeletal system. Therapeutic planning whether surgical or medical was to a great extent aided by the anatomic information available from these images.

Conclusion

3-D CT imaging is a rapid, non-invasive and accurate technique for diagnosis, pre-operative evaluation as well as post-operative assessment of a large number of musculoskeletal diseases. 3-D CT studies have come to stay and with continued improvement in CT technology it has now become an integral part of imaging studies of the musculoskeletal system.Key Words: Spiral CT, 3-dimensional imaging, Musculoskeletal system     

Hepatic portal venous gas – three non-fatal cases and review of the literature

Background

Hepatic portal venous gas is a rare imaging finding most commonly associated with intestinal ischaemia and high mortality. Increased use of advanced imaging techniques has resulted in increased reporting and recognition of hepatic portal venous gas. Advanced imaging can also recognise the many associated pathologies which have variable management strategies and prognoses.

Methods

We report 3 non-fatal cases and review the pathogenesis, aetiology, diagnosis, management and prognosis of hepatic portal venous gas.

Conclusion

Once considered an indication for urgent surgery, hepatic portal venous gas is a rare imaging finding. More recently, HPVG has been recognised to be associated with various benign causes many of which may be treated non-operatively. However, intestinal ischaemia remains the most common cause and the most important to exclude. CT is the diagnostic modality of choice. The underlying cause determines the treatment strategy and outcome.     

Research and applications: Imaging informatics for consumer health: towards a radiology patient portal

Objective

With the increased routine use of advanced imaging in clinical diagnosis and treatment, it has become imperative to provide patients with a means to view and understand their imaging studies. We illustrate the feasibility of a patient portal that automatically structures and integrates radiology reports with corresponding imaging studies according to several information orientations tailored for the layperson.

Methods

The imaging patient portal is composed of an image processing module for the creation of a timeline that illustrates the progression of disease, a natural language processing module to extract salient concepts from radiology reports (73% accuracy, F₁ score of 0.67), and an interactive user interface navigable by an imaging findings list. The portal was developed as a Java-based web application and is demonstrated for patients with brain cancer.

Results and discussion

The system was exhibited at an international radiology conference to solicit feedback from a diverse group of healthcare professionals. There was wide support for educating patients about their imaging studies, and an appreciation for the informatics tools used to simplify images and reports for consumer interpretation. Primary concerns included the possibility of patients misunderstanding their results, as well as worries regarding accidental improper disclosure of medical information.

Conclusions

Radiologic imaging composes a significant amount of the evidence used to make diagnostic and treatment decisions, yet there are few tools for explaining this information to patients. The proposed radiology patient portal provides a framework for organizing radiologic results into several information orientations to support patient education.