CT sign of brain swelling without concomitant parenchymal hypoattenuation: comparison with diffusion- and perfusion-weighted MR imaging

PURPOSE: To retrospectively evaluate the apparent diffusion coefficient (ADC) on magnetic resonance (MR) images and the perfusion parameters of lesions that show brain swelling without concomitant parenchymal hypoattenuation on computed tomographic (CT) scans. MATERIALS AND METHODS: Review board approval was obtained, and informed consent was waived. A total of 14 patients (seven men and seven women; mean age, 64 years +/- 11) were retrospectively selected from the consecutive 172 patients with acute cerebral ischemia who underwent CT within 6 hours of symptom onset. All patients had brain swelling without parenchymal hypoattenuation, including loss of gray-white matter distinction on CT scans, and they underwent diffusion- and perfusion-weighted MR imaging shortly after CT. CT attenuation, ADC, and perfusion parameters of relative cerebral blood volume (CBV), time to peak (TTP), and relative cerebral blood flow (CBF) were calculated for gray and white matter of the lesion. The measured values were compared with those of the contralateral hemisphere by using the paired t test; comparison of values of perfusion parameters among three subgroups was performed with the Kruskal-Wallis test. Arterial occlusions were determined with MR angiography or conventional angiography. RESULTS: The mean interval between initial CT and MR imaging was 2.4 hours +/- 0.9 (range, 0.4-3.4 hours). The ADC of lesions was similar to that of contralateral normal tissue (mean ADC ratio for gray matter and white matter, 0.99 and 0.97, respectively) (P > .05). Lesions had an increased relative CBV (P < .001), a mild to moderate TTP delay (P < .001), and a variable but not statistically significant reduction of relative CBF. The mean relative CBF of gray matter was less in patients who had complete infarction (0.81 +/- 0.16) than that in patients with partial infarction (0.99 +/- 0.16) or those with a normal radiologic outcome (1.12 +/- 0.22), but this difference was not statistically significant (P > .05). Proximal cerebral artery occlusions were found in all patients. In five (36%) patients, the lesion did not progress to infarction at follow-up. CONCLUSION: The CT sign of brain swelling without concomitant parenchymal hypoattenuation in patients with acute cerebral ischemia does not represent severe ischemic damage and may suggest ischemic penumbral or oligemic tissue.     

Incidental ovarian 18F-FDG accumulation on PET: correlation with the menstrual cycle

Purpose The aim of this study was to determine the nature of incidental ovarian ¹⁸F-fluoro-2-deoxyglucose (FDG) accumulation on positron emission tomography (PET) and the correlation with the menstrual cycle and menopause.Methods We identified 19 incidental FDG accumulations in the ovary (FAOs). FDG PET images were compared with other anatomical imaging methods [magnetic resonance imaging (MRI), computed tomography (CT) or ultrasonography (US)]. Pathological findings, FDG PET scan during the next menstrual cycle and follow-up images (PET, CT and MRI) were reviewed. To establish the relation of FAOs to the menstrual cycle, we reviewed whole-body FDG PET acquired from 207 consecutive women and the pre-examination questionnaires, including data regarding the menstrual cycle.Results All spherical or discoid FAOs were attributed to normally developing ovarian follicles and corpora lutea on the basis of concurrent MRI, US or the follow-up PET scan. Three of the FAOs were proved pathologically to be either normal ovaries or a haemorrhagic corpus luteum. Fifteen FAOs spontaneously disappeared on the short-term follow-up PET scans. Of 207 women, 61 had active menstrual cycles. FAOs were found in 12 out of 61 premenopausal women (20%), appearing between the 10th and 25th days of the menstrual cycle. No FAOs were found in the women who did not have a menstrual cycle.Conclusion Physiological ovarian FDG accumulation could be found around the time of ovulation and during the early luteal phase of the menstrual cycle in premenopausal woman. Since FAO is dependent on the menstrual cycle, it can be avoided by scheduling PET just after menstruation.     

Value of extranodal extension detected by computed tomography for predicting clinical response after chemoradiotherapy in head and neck squamous cell cancer

Objectives: Radiological extranodal extension (rENE) upon CT is obtained before concurrent chemoradiation therapy (CCRT) for head and neck squamous cell carcinoma (HNSCC). We evaluated the prognostic value of rENE, rather than pathologically proven ENE, in patients who received CCRT for HNSCC.

Materials and methods: We reviewed 117 patients. We divided the patients into rENE(+) and rENE(?) groups and evaluated overall survival (OS) and disease-specific survival (DSS), and factors affecting these outcomes.

Results: Median follow-up was 37.4 months; 31 patients (26.2%) died and 26 (22.2%) had recurrence. Thirty patients were rENE(+) and these had worse 5-year OS (74% vs. 94%, p?p?n?=?87). rENE (hazard ratio [HR] 3.57, p?p?p?p?p?p?Conclusions: CT findings suggesting ENE predicts treatment response to CCRT and prognosis, and could be used to determine the treatment modality for HNSCC.     

The Role of Cytology in the Preoperative Assessment and Management of Patients with Pancreaticobiliary Tract Neoplasms

Objective

Endoscopic ultrasound-guided fine-needle aspiration and bile duct brushings are utilized in the cytologic evaluation of solid and cystic pancreaticobiliary tract lesions. We sought to determine the diagnostic accuracy of cytology.

Methods

Five hundred seventy-nine pancreatic resections with 727 corresponding cytology specimens were identified from 1997 to 2012. Histologic diagnoses included benign, carcinoma, pancreatic endocrine neoplasm (PEN), nonepithelial neoplasms, cystic neoplasms, and ampullary adenomas. Standard interpretative categories—nondiagnostic, negative, atypical, suspicious, and positive—were utilized for preoperative cytology specimens.

Results

For solid masses, the sensitivity and specificity of positive fine-needle aspiration (FNA) cytology for detecting carcinoma were 74 and 100 %, respectively. FNAs performed better than brushings (sensitivity, 40 %; specificity, 98 %) in detecting carcinomas. Similar findings were seen for PENs and nonepithelial neoplasms. For cystic lesions, the sensitivity of FNA for predicting malignancy was lower (24 %) with a specificity of 97 %. Sequentially combining suspicious and atypical categories with the positive category resulted in increases in sensitivity and decreases in specificity for all cases except for cystic lesions.

Conclusions

Cytology adds to the assessment of solid masses, but its utility in cystic lesions is less clear. Consideration of a suspicious cytologic interpretation as a positive diagnosis for triaging patients to surgery is supported by our study.     

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture

Purpose

Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF.

Methods

A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I.

Results

Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively).

Conclusions

High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.     

Increased arterial pulsatility and progression of single subcortical infarction

Objective

We investigated the association of clinical, laboratory, sonographic and imaging parameters, in the progression of single subcortical infarctions.

Methods

Consecutive 169 patients with lacunar (n?=?89) and striatocapsular infarctions (n?=?80) in the middle cerebral artery (MCA) territory with nonstenotic MCAs were recruited and examined for stroke progression. The pulsatility index (PI) was measured by transcranial Doppler from ipsilateral M1.

Results

The striatocapsular infarction group exhibited more stroke progression. The patients with progressive lacunar infarctions had more diabetes, higher HbA1c levels, and higher initial National Institutes of Health Stroke Scale (NIHSS) scores, and the patients with progressive striatocapsular infarctions had more hypertension, higher cholesterol levels, and higher NIHSS scores. The MCA PI was higher in the lacunar infarction patients with progression (0.99?±?0.19 vs. 0.90?±?0.14, p?=?0.048), while the striatocapsular infarction patients did not differ according to progression. From a multivariate analysis, higher MCA PI were independently associated with lacunar infarction progression (by 0.1 increase, OR 1.51; 95 % CI 1.06–2.15; p?=?0.024).

Conclusions

Higher pulsatility was associated with progression in lacunar infarction. PI measured by transcranial Doppler sonography might reflect downstream arterial resistance and vascular/paravascular perfusion status and be a possible indicator of stroke progression.

Key Points

? Higher pulsatility index was observed in progression group of lacunar infarction patients. ? Higher pulsatility index seemed to be associated with progression in lacunar infarction patients. ? Differences in the factors associated with stroke progression suggest different underlying pathophysiologies.

     

Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies

BACKGROUND: The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, multifocality, or inadequate functional hepatic reserve. Cryoablation has become a common treatment in select groups of these patients with unresectable liver tumors. However, hepatic cryoablation is associated with significant morbidity. Radiofrequency ablation (RFA) is a technique that destroys liver tumors in situ by localized application of heat to produce coagulative necrosis. In this study, we compared the complication and early local recurrence rates in patients with unresectable malignant liver tumors treated with either cryoablation or RFA. PATIENTS AND METHODS: Patients with hepatic malignancies were entered into two consecutive prospective, nonrandomized trials. The liver tumors were treated intraoperatively with cryoablation or RFA; intraoperative ultrasonography was used to guide placement of cryoprobes or RFA needles. All patients were followed up postoperatively to assess complications, treatment response, and local recurrence of malignant disease. RESULTS: Cryoablation was performed on 88 tumors in 54 patients, and RFA was used to treat 138 tumors in 92 patients. Treatment-related complications, including 1 postoperative death, occurred in 22 of the 54 patients treated with cryoablation (40.7% complication rate). In contrast, there were no treatment-related deaths and only 3 complications after RFA (3.3% complication rate, P<0.001). With a median follow-up of 15 months in both patient groups, tumor has recurred in 3 of 138 lesions treated with RFA (2.2%), versus 12 of 88 tumors treated with cryoablation (13.6%, P<0.01). CONCLUSIONS: RFA is a safe, well-tolerated treatment for patients with unresectable hepatic malignancies. This study indicates that (1) complications occur much less frequently following RFA of liver tumors compared with cryoablation of liver tumors, and (2) early local tumor recurrence is infrequent following RFA.