Differentiation between classic and atypical meningiomas with use of diffusion tensor imaging

BACKGROUND AND PURPOSE:The differentiation between classic and atypical meningiomas may have implications in preoperative planning but may not be possible on the basis of conventional MR imaging. Our hypothesis was that classic and atypical meningiomas have different patterns of intratumoral water diffusion that will allow for differentiation between them.MATERIALS AND METHODS:Preoperative diffusion tensor imaging (DTI) was performed in 12 classic and 12 atypical meningiomas. Signal intensity of solid-enhancing tumor regions on diffusion-weighted trace images and apparent diffusion coefficient (ADC) and fractional anisotropy (FA) maps was assessed. Regions of interest (ROIs) were placed in solid-enhancing regions, peritumoral edema, and contralateral normal-appearing white matter (NAWM) to measure tensor metrics including major (λ₁), intermediate (λ₂) and minor eigenvalues (λ₃) and FA and ADC values. Distribution of tensor shapes within enhancing tumors was calculated for all tumors. Differences between classic and atypical meningiomas in tumor signal intensity, intratumoral and peritumoral tensor metrics, as well as tensor shapes distribution were statistically analyzed.RESULTS:A significantly greater proportion of atypical meningiomas were isointense and hypointense on ADC maps (P = .007). Classic meningiomas had significantly lower FA (P = .012), higher ADC (P = .011), greater λ₂ (P = .020) and λ₃ (P = .003). There was significantly more spherical diffusion in classic than in atypical meningiomas (P = .020). All diffusion tensor metrics for peritumoral edema of the 2 tumor groups did not differ.CONCLUSION:DTI showed that intratumoral microscopic water motion is less organized in classic than in atypical meningiomas. This feature may allow for noninvasive differentiation between classic and atypical meningiomas.

Meningiomas account for between 16% and 20% of primary intracranial tumors.¹ According to the World Health Organization (WHO) classification system, 78% of meningiomas are grade I, 20.4% are grade II, and 1.6% are grade III.² Grades II and III meningiomas are more aggressive than grade I meningiomas. Five-year recurrence rates are 12% for benign meningiomas and 41% for atypical meningiomas.² Initial extent of tumor resection and histologic grade are key determinants for recurrence.³ Therefore, prospectively identifying their histologic grades can be clinically beneficial in treatment planning. Although conventional MR imaging can provide detailed morphologic information of meningiomas, its value in the prediction of WHO grades is limited.⁴According to the WHO classification,⁵ classic meningiomas differ from atypical ones in their number of mitoses, cellularity, and nucleus-to-cytoplasm ratio (N/C ratio) as well as their histologic patterns. Complex microstructural barriers in brain tissue, such as white matter tracts, cell membranes, and capillary vessels result in a tendency for water molecules to diffuse with direction (anisotropic diffusion) rather than equally in all directions (isotropic diffusion). Isotropic diffusion-weighted imaging (DWI), which measures average magnitude of water motion in apparent diffusion coefficient (ADC), has shown controversial results for differentiating classic from atypical meningiomas.^6-8 In contrast to isotropic DWI, diffusion tensor imaging (DTI) provides information about magnitude and directionality of water diffusion⁹ and thus may be able to measure the differences in intratumoral diffusion anisotropy as a result of histologic differences between classic and atypical meningiomas. On the other hand, peritumoral edema associated with meningiomas, regardless of classic or atypical subtypes, has always been considered a purely vasogenic edema (ie, absence of tumor cell infiltration).^10,11Our first hypothesis was that intratumoral diffusion anisotropy is different between these 2 tumor types and that differences in diffusion anisotropy as detected by DTI allow differentiation between them. Our second hypothesis was that anisotropic diffusion measured in peritumoral edema with DTI will not be different between classic and atypical meningiomas.     

Free fillet foot flap for salvage of below-knee amputation stump

Management of extensive bone and soft tissue defects, which occur after severe trauma of lower extremities and always lead to anunacceptable amputation in some cases, continues to challenge reconstructive surgeons. When performing lower extremity amputation, preservation of the knee joint has been put into a higher priority. The benefit of below-knee amputation over above-knee ones concentrates on a more normal gait with less energy expenditure during ambulation when a functioning knee joint is present.     

Complex regional pain syndrome: a review

Complex regional pain syndrome (CRPS), formerly known as "reflex sympathetic dystrophy," is a chronic neurological disorder characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. The disorder usually develops after minor trauma or surgery. No specific diagnostic test is available and, hence, diagnosis is based mainly on history, clinical examination, and supportive laboratory findings. This review gives a synopsis of CRPS and discusses the principles of management based on the limited available literature in the area. A literature search was conducted using electronic bibliographic databases (Medline, Embase, Pubmed, CENTRAL) from 1970 to 2006. Keywords complex regional pain syndrome, reflex sympathetic dystrophy, neuropathic pain, and causalgia were used for the search. Relevant articles from the reference lists in retrieved articles were also studied. There were 3,771 articles published in the area. Seventy-six randomized controlled trials were identified. Most studies were on the role of sympathetic blockade in the treatment of CRPS (n = 13). The role of sympathectomy is unclear, with some studies showing transient benefit and others showing no beneficial effects, with most studies containing only a small number of patients. Nine studies were on bisphosphonates or calcitonin. Studies involving bisphosphonates showed benefit, but studies involving calcitonin showed no definite benefit. Four studies were on cognitive behavioral therapy, physiotherapy, or occupational therapy, all of which demonstrated a potential beneficial effect. Three studies on spinal cord stimulation and two studies each on acupuncture, vitamin C, and steroid all showed a potential beneficial effect in pain reduction. The remaining studies were on miscellanous therapy or combination therapy, making it difficult to draw any conclusions on the effect of treatment. There is very little good evidence in the literature to guide treatment of CRPS. Early recognition and a multidisciplinary approach to management seems important in obtaining a good outcome. Treatments aimed at pain reduction and rehabilitation of limb function form the mainstay of therapy. Comorbidities, such as depression and anxiety, should be treated concurrently.     

Superdrainage of the ileocolic vein to the internal jugular vein interposed by an inferior mesenteric vein graft in replacing the esophagus with the right hemicolon

The fear of serious complications, such as a necrotic conduit caused by an impaired blood circulation can arise when replacing the esophagus with an intestinal conduit. The aim of this paper is to present effective superdrainage of an intestinal conduit using an inferior mesenteric vein (IMV) interposition graft. In 2008, we performed superdrainage of the ileocolic vein to the internal jugular vein interposed by an IMV graft in replacing the esophagus with the right hemicolon for advanced thoracic esophageal cancer in three patients with a synchronous gastric cancer or a previous gastrectomy. No leakage at the enteric anastomoses occurred. Neither ischemic lesions in these intestinal conduits nor complications caused by harvesting an IMV graft were observed. Superdrainage of the ileocolic vein to the internal jugular vein interposed by an IMV graft effectively improves the blood circulation in intestinal conduits brought up to the neck as an esophageal replacement.     

Surgical outcomes of foramen magnum decompression for syringomyelia associated with Chiari I malformation: relation between the location of the syrinx and body pain

Background  

There have been few reports about the relation between the morphology of syrinxes and body pain in syringomyelia associated with Chiari I malformation. To investigate this phenomenon, the relation between the location of the syrinx and body pain before and after foramen magnum decompression (FMD) were evaluated.     

Mental Well‐Being Mediates the Relationship between Perceived Stress and Perceived Health

The association between stress and health has been well researched in the past; however, comparatively few mediators have been tested to understand the underlying mechanism. With increasing awareness on mental well‐being, this study evaluated the relationship between perceived stress and perceived health and examined mental well‐being as a mediator. Two‐hundred undergraduates aged 21 to 26 years completed the English Perceived Stress Scale, Health Status Questionnaire and Asian Mental Well‐Being Scale that assess perceived stress, perceived health and mental well‐being, respectively. Factor analysis and structural equation modelling on the Perceived Stress Scale replicated the reported two‐factor structure after excluding an insignificant item. Linear multiple regression analyses indicated that perceived stress was negatively associated with perceived health. Results showed that mental well‐being partially mediated the relationship between perceived stress and perceived health, although it is acknowledged that this association could be bidirectional. Findings from the present study suggest that future research could focus on reducing stress and improving mental well‐being to alleviate the effect of stress on health. Copyright © 2013 John Wiley & Sons, Ltd.     

Prostate cancer detection upon transrectal ultrasound-guided biopsy in relation to digital rectal examination and prostate-specific antigen level: what to expect in the Chinese population?

We investigated the prostate cancer detection rates upon transrectal ultrasound (TRUS)-guided biopsy in relation to digital rectal examination (DRE) and prostate-specific antigen (PSA), and risk factors of prostate cancer detection in the Chinese population. Data from all consecutive Chinese men who underwent first TRUS-guided prostate biopsy from year 2000 to 2013 was retrieved from our database. The prostate cancer detection rates with reference to DRE finding and PSA level of < 4, 4–10, 10.1–20, 20.1–50 and > 50 ng ml⁻¹ were investigated. Multivariate logistic regression analyses were performed to investigate for potential risk factors of prostate cancer detection. A total of 2606 Chinese men were included. In patients with normal DRE, the cancer detection rates were 8.6%, 13.4%, 21.8%, 41.7% and 85.2% in patients with PSA < 4, 4–10, 10.1–20, 20.1–50 and > 50 ng ml⁻¹ respectively. In patients with abnormal DRE, the cancer detection rates were 12.4%, 30.2%, 52.7%, 80.6% and 96.4% in patients with PSA < 4, 4–10, 10.1–20, 20.1–50 and > 50 ng ml⁻¹ respectively. Older age, smaller prostate volume, larger number of biopsy cores, presence of abnormal DRE finding and higher PSA level were associated with increased risk of prostate cancer detection upon multivariate logistic regression analyses (P < 0.001). Chinese men appeared to have lower prostate cancer detection rates when compared to the Western population. Taking the different risk factors into account, an individualized approach to the decision of TRUS-guided biopsy can be adopted.     

Tibialis Posterior Tendon Rupture Associated with a Closed Medial Malleolar Fracture: A Case Report and Review of the Literature

We report an acute rupture of a macroscopically normal tibialis posterior tendon in the setting of an acute closed ankle fracture. This injury is considered to be rare, although it is probably frequently overlooked preoperatively because of limitations of the clinical examination secondary to pain. The tibialis posterior tendon rupture was identified at the time of operative repair of the ankle fracture, and direct suture repair of the tendon was undertaken. After primary suture and osteosynthesis, the patient’s progress was favorable and a satisfactory outcome was achieved. A clear history of the mechanism of injury as well as a high index of suspicion should be maintained, because failure to repair rupture of the tibialis posterior tendon, in the presence of an ankle fracture, is likely to lead to long-term patient disability and a planovalgus foot.     

Optimum Treatment Strategy for Superficial Esophageal Cancer: Endoscopic Mucosal Resection versus Radical Esophagectomy

This study was designed to determine the optimum treatment for a superficial esophageal cancer involving the mucosal or submucosal layer of the esophagus. The subjects were 150 patients with a superficial esophageal cancer who underwent endoscopic mucosal resection (EMR) or esophagectomy in Kurume University Hospital from 1981 to 1997. The mortality and morbidity rates, survival rate, and recurrence rate were retrospectively compared for (1) 35 patients who underwent EMR and 37 patients who underwent esophagectomy for a mucosal esophageal cancer and (2) 45 patients who underwent extended radical esophagectomy and 33 patients who underwent less radical esophagectomy for a submucosal esophageal cancer. Among the 72 patients with a mucosal cancer, lymph node metastasis/recurrence was observed in only one (1%); whereas of 78 patients with a submucosal cancer it was observed in 30 (38%). Among patients with a mucosal cancer the mortality and morbidity rates after EMR were lower than for those after esophagectomy. The survival rate after EMR was the same as that after esophagectomy. No recurrence was observed after either treatment modality. Among the patients with a submucosal cancer, the survival rate was higher and the recurrence rate lower after extended radical esophagectomy; than after less radical esophagectomy; the mortality and morbidity rates after extended radical esophagectomy were the same as those after less radical esophagectomy. Multivariate analysis demonstrated that the treatment modality (EMR versus esophagectomy) did not influence the survival of patients with a mucosal esophageal cancer, whereas it strongly influenced the survival of patients with a submucosal esophageal cancer. We concluded that EMR was the mainstay of treatment for a mucosal esophageal cancer, and extended radical esophagectomy was the mainstay of treatment for a submucosal esophageal cancer.