Clinical Predictors of Significant Findings on Head Computed Tomographic Angiography

Background: Although head computed tomographic angiography (CTA) is a sensitive tool for the evaluation of neurological symptoms in the emergency department (ED), little is known about which clinical signs predict significant CTA findings. Objectives: To identify clinical factors that predict significant findings on head CTA in patients presenting to the ED with neurological complaints. Methods: Retrospective chart review of consecutive adult patients undergoing head CTA over a 6-month period in an urban, tertiary care ED with an annual volume of 76,000. Significant head CTA findings were defined as clinically significant neurological abnormalities undetected by previous imaging studies. Demographics, chief complaint, results of the neurological examinations (NE), and head non-contrast computed tomography (CT) results were used as predictors of significant head CTA. All predictors with a univariate p < 0.2 using Pearson's chi-squared were entered stepwise into a multivariable logistic regression including odds ratios (OR), with inclusion restricted to p < 0.05. Results: Chart review yielded 456 cases; 215 (47%) were male. Mean age was 62 (SD 20) years. There were 189 patients (41%) with abnormal CTAs. Multivariable logistic regression indicated five variables that predicted a clinically significant CTA: abnormal CT (OR 3.72), chief complaint of subarachnoid hemorrhage-type headache (OR 2.30), and motor deficit (OR 2.23), visual deficit (OR 2.23), and other focal deficit (OR 2.18) on NE. A chief complaint of trauma (OR 0.23) predicted a normal CTA. Conclusions: Specific historical and focal neurological findings are useful for predicting clinically significant findings on head CTA.     

Hyperglycemic choreoathetosis: Role of the putamen in pathogenesis

Hyperglycemic choreoathetosis (HC) is an uncommon syndrome often associated with hyperintensity of the basal ganglia on MRI. We performed a retrospective review of cases with HC to characterize the clinical, biochemical, and neuroimaging (CT, MRI, and MR spectroscopy) findings and to propose a mechanism for this syndrome. Seven HC patients with a mean age of 75.1 years, mean blood glucose of 27.4 mmol/L, and mean plasma osmolarity of 313.4 mmol/L were studied. All had MR‐T1 hyperintensity of the putamen on the side contralateral to the choreoathetosis. Two patients had additional hyperintensity of the globus pallidus while one also had involvement of the caudate. On MR‐T2, 2 patients showed hyperintensity, 2 isointensity, and 3 hypointensity in the putamen. MR spectroscopy showed elevated choline and reduced N‐acetylaspartate; two patients also had elevated myoinositol levels. Our findings suggest that the putamen has a central role in HC, and MR spectroscopy supports neuronal dysfunction in the putamen. Biochemical and neuroimaging findings support hyperviscosity as the most plausible mechanism. © 2009 Movement Disorder Society     

Retrospective analysis of pre- and peri-operative imaging in confirmed proximal colonic cancers – possible implications for screening flexible sigmoidoscopy

Objective  Faecal occult blood testing is being introduced for population screening in the United Kingdom. Flexible sigmoidoscopy may provide a viable alternative. The outcomes of the flexible sigmoidoscopy trial are awaited but the most obvious disadvantage is that only the lower third of the colon is examined and proximal pathology cannot be excluded. The relationship between proximal pathology and distal findings at flexible sigmoidoscopy is uncertain. The aim of this study was to determine the incidence of distal neoplasia in patients with confirmed proximal cancers of the colon.
Method  All confirmed proximal colonic cancers (defined as those proximal to the splenic flexure) were identified from a database of pathology specimens at a single centre between January 1999 and August 2006. A retrospective analysis of preoperative and peri-operative mucosal imaging (contrast enema, colonoscopy and CT colonography) was conducted to identify any distal neoplasia in these patients.
Results  A total of 348 patients were identified. Pre- or peri-operative mucosal imaging was identified in 231 (66%) and 49 (21%) had distal neoplasia. Nineteen (8%) of these patients would have gone on to have a colonoscopy based on the UK flexible sigmoidoscopy trial protocol and 92% of the cohort would not have had a colonoscopy.
Conclusion  Nearly 80% of confirmed proximal cancers in our series did not have any demonstrable distal neoplasia. Only 8% of our cohort would have proceeded to colonoscopy. A very significant number of proximal cancers would not have been detected.     

The pre-operative neutrophil–lymphocyte ratio predicts overall and disease-free survival following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with pseudomxyoma peritonei of appendiceal origin

Aim: The neutrophil–lymphocyte ratio (NLR) and other inflammation-based scores have been used as a prognostic tool to predict survival in solid tumours including pseudomyxoma peritonei (PMP). The aim was to evaluate the prognostic value of this marker and risk stratify PMP patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods: Retrospective analysis was conducted of a prospectively collected database of patients with PMP who underwent CRS and HIPEC between 1994 and 2015. The NLR was calculated by dividing the pre-operative neutrophil count by lymphocyte count. Predicted overall survival (OS) and disease-free interval (DFI) were calculated using a Kaplan–Meier survival model.

Results: The study included 699 patients, stratified into four groups as defined by their NLR. Group A: 200 (28.6%) patients (NLR?=?0.10–2.00), Group B: 160 (22.8%) patients (NLR?=?2.10–2.78), Group C: 184 (26.3%) patients (NLR?=?2.79–4.31) and Group D: 155 (22.2%) patients (NLR?≥?4.32). The median follow-up for this cohort was 36?months. The predicted DFI was 132.2, 113.1, 84.4 and 47.9?months and the OS was 141.1, 117.6, 88.7 and 51.2?months for Groups A, B, C and D, respectively. As the NLR increases, there is a reduction in long-term survival.

Conclusion: The pre-operative NLR is cost effective and has equivalent prognostic value to pre-operative tumour markers for patients with PMP treated with CRS and HIPEC. The NLR is a reliable tool that may have a role in predicting outcomes following CRS and HIPEC for patients with PMP of appendiceal origin.     

Subcortical Atrophy Is Associated with Cognitive Impairment in Mild Parkinson Disease: A Combined Investigation of Volumetric Changes,Cortical Thickness,and Vertex-Based Shape Analysis

BACKGROUND AND PURPOSE:The involvement of subcortical deep gray matter and cortical thinning associated with mild Parkinson disease remains poorly understood. We assessed cortical thickness and subcortical volumes in patients with Parkinson disease without dementia and evaluated their associations with cognitive dysfunction.MATERIALS AND METHODS:The study included 90 patients with mild Parkinson disease without dementia. Neuropsychological assessments classified the sample into patients with mild cognitive impairment (n = 25) and patients without cognitive impairment (n = 65). Volumetric data for subcortical structures were obtained by using the FMRIB Integrated Registration and Segmentation Tool while whole-brain, gray and white matter volumes were estimated by using Structural Image Evaluation, with Normalization of Atrophy. Vertex-based shape analyses were performed to investigate shape differences in subcortical structures. Vertex-wise group differences in cortical thickness were also assessed. Volumetric comparisons between Parkinson disease with mild cognitive impairment and Parkinson disease with no cognitive impairment were performed by using ANCOVA. Associations of subcortical structures with both cognitive function and disease severity were assessed by using linear regression models.RESULTS:Compared with Parkinson disease with no cognitive impairment, Parkinson disease with mild cognitive impairment demonstrated reduced volumes of the thalamus (P = .03) and the nucleus accumbens (P = .04). Significant associations were found for the nucleus accumbens and putamen with performances on the attention/working memory domains (P < .05) and nucleus accumbens and language domains (P = .04). The 2 groups did not differ in measures of subcortical shape or in cortical thickness.CONCLUSIONS:Patients with Parkinson disease with mild cognitive impairment demonstrated reduced subcortical volumes, which were associated with cognitive deficits. The thalamus, nucleus accumbens, and putamen may serve as potential biomarkers for Parkinson disease–mild cognitive impairment.

Parkinson disease (PD) has traditionally been considered a motor disorder. However, the presence of cognitive dysfunction is increasingly recognized and known to occur even at early stages, and most patients develop dementia during the course of the disease. Recently, it has emerged that patients with PD show a wide and variable spectrum of cognitive deficits involving multiple domains such as executive function, attention, memory, visuospatial, and, less frequently, language.^1,2 While traditionally believed to occur only in advanced stages of PD, recent studies suggest that approximately 30%–35% of patients with early PD experience cognitive disturbances,^3,4 which have been defined as mild cognitive impairment (MCI).⁵ The Movement Disorder Society (MDS) Task Force reported a mean prevalence of Parkinson disease with mild cognitive impairment (PD-MCI) at 27%, ranging from 19% to 38%.⁶ Furthermore, the impact of MCI and dementia in patients with PD at any given stage of the disease is substantial, with adverse consequences for functioning,⁷ psychiatric morbidity, caregiver burden,⁸ and mortality.⁹ At present, there is much to be elucidated with regard to the etiology of cognitive impairment in PD.Initially, dementia in PD was described as subcortical. Cognitive dysfunction in patients without dementia has also been attributed to dopaminergic depletion disrupting the frontostriatal circuit¹⁰ or dopamine-acetylcholine synaptic imbalance.¹¹ Nevertheless, recent investigations by using structural MR imaging suggest that specific cognitive deficits, such as memory deficits, and dementia in PD may also be accompanied by structural cerebral abnormalities. In this regard, MR imaging studies have demonstrated cortical atrophy in patients with PD with dementia. A recent meta-analysis revealed regional gray matter reductions of the medial temporal lobe and the basal ganglia,¹² while other areas, including the caudate,¹³ hippocampus,¹⁴ and amygdala,¹⁵ have also been implicated. However, present findings on GM atrophy in patients without dementia with PD are inconclusive. While a few studies have demonstrated atrophy in the medial temporal lobes,¹⁶ amygdala,¹⁷ and frontal and parietal regions,¹⁸ others have reported no significant GM reductions in PD populations without dementia.¹⁹In addition, cortical thinning in PD represents a relatively new area of research, and it has been reported to be more sensitive than voxel-based morphometry.²⁰ Recent studies have shown that cortical thinning occurs in PD without dementia.²¹ A longitudinal study also reported that patients with early PD presented with a more aggressive rate of cortical thinning in the frontotemporal regions compared with healthy controls.²²These mixed neuroimaging findings could be due, in part, to cognitively heterogeneous groups of patients, particularly in studies in which patients with MCI were not distinguished from those with normal cognition. Therefore, to systematically compare the pattern of GM atrophy in mild PD and its impact on specific cognitive domains, we used the recent MDS Task Force criteria to classify patients with PD with MCI or as cognitively normal (PD-NCI). We estimated the volumes of the amygdala, hippocampus, nucleus accumbens, caudate nucleus, putamen, pallidum, and thalamus in a cohort of patients with PD by using the FMRIB Integrated Registration and Segmentation Tool (FIRST; http://fsl.fmrib.ox.ac.uk/fsl/fslwiki/FIRST).Furthermore, we assessed differences in subcortical deep gray matter (SDGM) structures between PD-MCI and PD-NCI and further examined associations between individual structures and cognitive performances across multiple domains. Because vertex analysis directly measures changes in geometry without any smoothing of the image data, it might have the potential to more precisely detect regional alterations of the subcortical GM than the conventional voxel-based morphometry approach.²³ Therefore, we used a vertex-based shape-analysis method to investigate potential shape differences of SDGM structures between PD-MCI and PD-NCI. Last, vertex-wise cortical thickness analysis was performed by using FreeSurfer (http://surfer.nmr.mgh.harvard.edu) to assess and compare patterns of regional cortical alterations between both PD groups.