Lobar Location Research Articles

Radiation-induced heart disease in lung cancer radiotherapy: A dosimetric update.

Background:Radiation-induced heart disease (RIHD), which affects the patients’ prognosis with both acute and late side effects, has been published extensively in the radiotherapy of breast cancer, lymphoma and other benign diseases. Studies on RIHD in lung cancer radiotherapy, however, are less extensive and clear even though the patients with lung cancer are delivered with higher doses to the heart during radiation treatment.Methods:In this article, after extensive literature search and analysis, we reviewed the current evidence on RIHD in lung cancer patients after their radiation treatments and investigated the potential risk factors for RIHD as compared to other types of cancers.Result:Cardiac toxicity has been found highly relevant in lung cancer radiotherapy. So far, the crude incidence of cardiac complications in the lung cancer patients after radiotherapy has been up to 33%.Conclusion:The dose to the heart, the lobar location of tumor, the treatment modality, the history of heart and pulmonary disease and smoking were considered as potential risk factors for RIHD in lung cancer radiotherapy. As treatment techniques improve over the time with better prognosis for lung cancer survivors, an improved prediction model can be established to further reduce the cardiac toxicity in lung cancer radiotherapy.

Clinical Predictors of Persistent Mediastinal Nodal Disease After Induction Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer

Patients with persistent N2 disease after induction have poor survival. Many of these patients may have had mediastinoscopy before induction therapy, making reassessment of the mediastinum by repeat mediastinoscopy hazardous and inaccurate. The sensitivity and specificity of endobronchial ultrasonography and nodal fine-needle aspiration in this setting is unclear. In this study, we sought to identify the clinical predictors of persistent N2 disease after induction therapy, which may help in selecting the patients most likely to benefit from surgical resection. A retrospective review of a prospective database (1990 to 2014) was performed to identify patients who had surgical resection after induction therapy for clinical stage IIIA-N2 non-small cell lung cancer. Multivariable logistic regression analysis was performed to determine independent predictors of persistent N2 disease. 203 patients (56% female; median age 64 years) underwent potentially curative lung resection after induction therapy. Ninety-seven patients (48%) had pathologic nodal downstaging (pN0/N1), which was associated with significantly better overall survival compared with patients with persistent N2 disease (5years, 56% versus 35%, p= 0.047). Univariate and multivariate analysis showed that upper or middle lobe location and less than 60% reduction of N2 SUVmax were independent predictors of persistent N2 disease. Patients with upper lobe tumors and less than 60% reduction in N2 SUVmax are more likely to have persistent N2 disease, which is often associated with poor survival rates. These clinical prognostic criteria may help surgeons in stratifying patients and properly selecting optimal surgical candidates.

Seizure control following treatment of brain arteriovenous malformations in pediatric patients.

Seizure outcome after treatment for pediatric patients with arteriovenous malformations (AVMs) has been rarely described in the literature. The aim of this study was to determine the risk factors for seizure presentation in pediatric AVM patients and the predictors for seizure control following treatment. We searched our characteristics of seizures associated with brain arteriovenous malformations prospectively maintained AVM database at Beijing Tiantan Hospital and identified 198 pediatric patients with brain AVMs between the year 2009 and 2014. Seizure presentation, patient characteristics, AVM features, treatment modalities, and postoperative outcomes, especially post-treatment seizure control were collected. Univariate and multivariate logistic regression analyses were applied to determine the risk factors for seizure presentation as well as the predictors for seizure control. Before initiation of any treatments, 63 (31.8%) of the overall 198 patients presented with seizure. According to multivariate analyses, larger AVM size, frontal AVM location, and history of prior hemorrhage were significantly associated with seizure presentation (all p<0.05). For patients with pre-treatment seizure presentation, good seizure outcome was achieved in 73.8%. AVM obliteration, short-period history of seizure, and short duration for seizure onset were independent predictors of good seizure outcome in the multivariate analysis. For the 135 patients without seizures at presentation, the overall rate of de novo seizures was 4.4%. In pediatric patients with brain AVMs, prior hemorrhage, larger AVM size, and frontal lobe location may predict subsequent seizures. Highest seizure control can be achieved by complete obliteration of the AVMs with microsurgical resection.

Local Fibrinolysis in Spontaneous Supratentorial Hematomas: Comparison with Surgical and Medical Treatment

Objective: To evaluate the effectiveness of minimally invasive craniopuncture with local fibrinolysis in the management of supratentorial spontaneous intracerebral hemorrhage (SICH). Methods: The study included 218 consecutive patients with supratentorial SICH who were assigned to one of three groups: treated with minimally invasive craniopuncture with local fibrinolysis, treated with craniotomy or other minimally invasive techniques without local fibrinolysis, or receiving conservative management alone. Results: Minimally invasive craniopuncture with local fibrinolysis was associated with a lower rate of assisted ventilation, a shorter period of in-hospital stay, a more frequent initiation of early rehabilitation, and a lower mortality rate at all periods of assessment. The overall mortality at 12 months was 19.4% (vs. 50.0 and 33.3% in the two other therapy groups). Lobar (subcortical and cortical) SICHs treated with local fibrinolysis had an overall mortality of 4.8% (vs. 43.5 and 41.7% in the two other therapy groups). On the other hand, SICHs having mixed (basal ganglia and lobar) locations treated with medical therapy alone had an overall mortality of 28.6%, while associated surgery with or without local fibrinolysis increased the overall mortality to over 65%. Conclusions: The study demonstrated the applicability of minimally invasive craniopuncture with local fibrinolysis for the management of supratentorial SICHs and the advantages it may have in certain categories of patients. The method proved particularly useful in lobar SICHs, being associated with the lowest mortality. Mixed SICHs do not represent a predilection for surgical interventions; however, the results related to mixed supratentorial locations need confirmation in larger cohorts.

SU‐F‐J‐119: Pilot Study On the Location‐Based Lung Motion Assessment

Purpose:In most of lung treatment cases with various radiotherapy beam modalities, 4DCT images are obtained in order to define ITV. ITV is defined with the signal from motion monitoring system, e.g. RPM. However, the signal is not consistent with tumor motion because it varies with location, its size, age, gender, etc. In the present study, the location‐based motion assessment is presented.Methods:4DCT images of 70 patients were reviewed: 28‐left‐lung and 42‐right‐lung patients; 36‐female and 34‐male patients; the age range of 51.2–89.9; tumor‐size range of 0.75–9.50cm with 25% of these adherent to bony‐anatomy. Philips Big‐Bore Simulation CT and RPM systems were used. The study was performed as follows. First, RPM signal and tumor motion in superior‐inferior direction was compared. Second, the tumor size and its motion amplitude in all directions were measured at multiple locations. Third, the average tumor motion was calculated to assess general motion amplitudes at various locations.Results:RPM amplitude is not consistent with lung tumor motion amplitude. The tumors of similar sizes at similar location present various motion amplitude up to 1.1cm difference, but in average, the standard deviation was &lt;0.5cm. Almost regardless of tumor sizes, the tumor motion was greatest at lower lobe location (&gt;=1.0cm), and the smallest at upper lobe location and when adherent to bony‐anatomy (&lt;=0.5cm).Conclusion:The tumor size affects the motion amplitude less than does the tumor location. However, as the study results indicate that tumor motion has noticeable variation and so further study with more patient cases is needed. Also, for the same patient, the RPM signal presents instability of breathing, and clinically the patient with the instability of RPM breathing of &lt;=10% is selected for respiratory‐gated radiotherapy and ∼25% of patients under current study was treated. Patient‐specific motion‐uncertainty margins are considered to be added following further study.

Pulmonary Function After Lobectomy: Video-Assisted Thoracoscopic Surgery Versus Muscle-Sparing Mini-thoracotomy.

Although pulmonary function was better after video-assisted thoracoscopic surgery (VATS) lobectomy than after open thoracotomy lobectomy, it is unclear whether postoperative pulmonary function after VATS lobectomy is better than that after mini-thoracotomy lobectomy. The aim of this study is to determine whether the former is better than the latter. VATS lobectomies were performed using endoscopic techniques through a 3-4-cm skin incision spread by a silicon rubber retractor and two or three trocars. Mini-thoracotomy lobectomies were performed through a 7-12-cm skin incision spread by rib retractors made of metal and one or two trocars. Pulmonary function tests were performed a week before surgery and 3months after surgery. There were 14 males and 11 females in VATS lobectomy and 32 males and 30 females in mini-thoracotomy lobectomy. For lobe location (right upper/right lower/left upper/left lower), there were 12/1/8/4 in VATS lobectomy and 16/19/13/14 in mini-thoracotomy lobectomy, respectively. The percent predicted postoperative forced vital capacity (FVC) (postoperative FVC/predicted postoperative FVC × 100) (110 ± 15%) of VATS lobectomy was significantly higher than that (101 ± 16%) of mini-thoracotomy lobectomy (P = 0.0124). The percent predicted postoperative forced expiratory volume in 1s (FEV1) (postoperative FEV1/predicted postoperative FEV1 × 100) (110 ± 15%) of VATS lobectomy was not significantly higher than that (104 ± 15%) of mini-thoracotomy lobectomy (P = 0.091). Multiple regression analysis revealed that operative procedure (VATS lobectomy or mini-thoracotomy lobectomy) was the only significant variable contributing to percent predicted postoperative FVC (P = 0.0073) and percent predicted postoperative FEV1 (P = 0.0180). Postoperative FVC after VATS lobectomy is better than after mini-thoracotomy lobectomy.

Occurrence predictors of the temporal interictal epileptic discharges in epilepsy patients with extratemporal lesions: A prospective cohort study

ObjectiveElectrical kindling models of epilepsy suggest that medial temporal structures are more prone to be irritated. The aim of this study is to investigate the occurrence rate of temporal interictal epileptic discharges (TIEDs) in the epilepsy patients with extratemporal lesions (ETLs), and to determine the predictive factors for TIEDs in this cohort. MethodsTotally 221 patients were admitted for presurgical evaluation, and focal ETL were found in all of them by MRI examination. The occurrence rates of TIEDs in several groups with different brain lobe locations, durations; of epilepsy, seizure frequencies, and onset ages stages were assessed. We also evaluated the surgical outcome of; resection in this cohort. ResultsThe total occurrence rate of TIEDs in this cohort was 29.9%. The occurrence rate of TIEDs in the patients with longer durations (>5 or 10 years) was significantly higher than those with shorter duration (<1 year). These; patients with lower seizure frequency (<1 seizure/month) had a significantly decreased incidence of TIEDs; compared with those with higher frequency (>1 seizure/month or week). In the terms of the brain lobe locations; and age at onset, there were no differences between the groups. Furthermore, there were no differences in terms of the surgical outcomes between the patients with TIEDs and other patients in this series. ConclusionsTIEDs were frequently recorded in these patients with ETLs, and the predictive factors for TIEDs included the epilepsy duration and seizure frequency. SignificanceThis study is instrumental for the presurgical EEG interpretationand the counseling of these ETLs patients considered for epilepsy surgery.

Use of [18F]Fluoro-2-deoxy-d-glucose Positron Emission Tomographic Imaging in the National Lung Screening Trial

Positron emission tomography (PET) is a diagnostic tool for lung cancer evaluation. No studies have ascertained practice patterns and determined the appropriateness of PET imaging in a large group of US patients with screen-detected lung nodules. We analyzed participants in the National Lung Screening Trial (NLST) with positive screening test results and identified individuals with a PET scan performed prior to lung cancer diagnosis (diagnostic PET). Appropriate scan was defined as one performed in a patient with a nodule≥ 0.8cm. Logistic regression was used to assess factors associated with diagnostic PET scan use and appropriateness of PET scan use. Diagnostic PET imaging was performed in 1,556 of 14,195 patients (11%) with positive screen results; 331 of these (21%) were inappropriate. PET scan use by endemic fungal disease area was comparable although patients from the Northeast/Southeast were twice as likely as the West to have a diagnostic PET. Trial arm, older age, sex, nodule size≥0.8cm, upper lobe location, and spiculated margin were variables positively associated with use. Trial arm, older age, and spiculated margin were positively associated with appropriate use. Only 561 diagnostic PETs (36%) were recommended by a radiologist and 284 PETs performed for nodules< 0.8cm (86%) were ordered despite no recommendation from a radiologist. PET imaging was differentially used in the NLST and inappropriately used in many cases against radiologist recommendations. These data suggest PET imaging may be overused in the lung cancer screening population and may contribute to excess health-care costs.

Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations.

OBJECTIVE Compared with the general population, the specific natural history of arteriovenous malformations (AVMs) in pediatric patients is less well understood. Furthermore, few pediatric studies have compared posttreatment hemorrhagic risk and functional outcome across different treatment modalities. The objective of this study was to elucidate these points. METHODS The authors retrospectively reviewed all pediatric patients with AVMs evaluated at their institution between 1990 and 2013. The AVM natural history was represented by hemorrhagic risk during the observation period. For treated patients, the observation period was defined as the interval between diagnosis and treatment. Posttreatment hemorrhagic risk and functional outcomes were also assessed. RESULTS A total of 124 pediatric patients with AVMs were evaluated, and 90 patients (72.6%) were retained through follow-up. The average patient age was 13.3 ± 3.8 years, with a mean follow-up period of 9.95 years. The overall AVM obliteration rate was 59.7%. Radiosurgery had an obliteration rate of 49.0%. Thirteen patients were managed conservatively. Four patients under observation hemorrhaged during a total interval of 429.4 patient-years, translating to an annual risk of 0.9%. Posttreatment hemorrhagic risk by treatment modalities were categorized as follows: surgery ± embolization (0.0%), radiosurgery ± embolization (0.8%), embolization alone (2.8%), surgery + radiosurgery ± embolization (3.5%), and observation (0.8%). A significantly higher risk of posttreatment hemorrhage was observed for patients with hemorrhagic presentation (p = 0.043) in multivariate analysis. Seizure presentation, frontal lobe location, nonheadache presentation, and treatment modality were significantly associated with increased risk of poor functional outcomes. CONCLUSIONS In this study of pediatric patients with AVMs, the natural history of hemorrhage was relatively low at 0.9%. Resection remained the optimal management for hemorrhage control and functional outcome perseverance in these pediatric patients with AVMs. AVM obliteration is a valid treatment goal, especially for patients with ruptured presentation, to prevent further hemorrhages later in life.

Association of serum vascular endothelial growth factor levels and cerebral microbleeds in patients with Alzheimer's disease.

The association between the presence of cerebral microbleeds (CMBs) and serum vascular endothelial growth factor (VEGF) levels in patients with Alzheimer's disease (AD) was investigated. Consecutive AD patients who underwent magnetic resonance examination with susceptibility-weighted imaging (SWI) were prospectively examined. The presence of CMBs on SWI was independently interpreted. The number and location of microbleeds were assessed. Demographics including age, sex and risk factors were obtained. Serum VEGF levels were measured with an enzyme-linked immunosorbent assay. Of the 146 AD patients included, 47 (32.2%) patients had CMBs on SWI. The CMBs were most commonly located in strictly lobar locations (29/47, 61.7%). The mean VEGF levels were higher in the patients with CMBs than in those without (336.72 ± 15.18 vs. 192.37 ± 11.34 pg/ml). Multivariate logistic regression analyses showed that, for each 10 pg/ml increase of VEGF levels, there was a significant increase in the presence of CMBs after adjusting for age and sex, and after additional adjustment for cardiovascular risk factors, silent lacunar infarction and white matter hyperintensity in patients with AD (odds ratio 2.37; 95% confidence interval 1.53-4.02, P = 0.004). Serum VEGF levels are associated with the presence of CMBs in patients with AD.

3:54 PMAbstract No. 372 - CT guided lung biopsy: a lesion’s lobar location and distance from pleura as independent risk factors for pneumothorax

3:54 PMAbstract No. 372 - CT guided lung biopsy: a lesion’s lobar location and distance from pleura as independent risk factors for pneumothorax

Outcomes Knowledge May Bias Radiological Decision-making

This research investigates whether an expectation of abnormality and prior knowledge might potentially influence the decision-making of radiologists, and discusses the implications for radiological expert witness testimony. This study was a web-based perception experiment. A total of 12 board-certified radiologists were asked to interpret 40 adult chest images (20 abnormal) twice and decide if pulmonary lesions were present. Before the first viewing, a general clinical history was given for all images: cough for 3+ weeks. This was called the "defendants read." Two weeks later, the radiologists were asked to view the same dataset (unaware that the dataset was unchanged). For this reading, the radiologists were given the following information for all images: "These images were reported normal but all of these patients have a lung tumour diagnosed on a subsequent radiograph 6 months later." They were also given the lobar location of the newly diagnosed tumor. This was called the "expert witness read." There was a significant difference in location-based sensitivity (W = -45, P = 0.02) between the two conditions with nodule detection increasing under the second condition. Specificity increased outside the lobe of interest (W = 727, P = < 0.0001) and decreased within the lobe of interest (W = -237, P = 0.03) significantly in the "expert witness" read. Case-based sensitivity and case-based specificity were unaffected. This study showed evidence that increased clinical information affects the performance of radiologists. This effect may bias expert witnesses in radiological malpractice litigation.

Fontan-associated liver disease: Spectrum of US findings

PurposeTo describe ultrasonography (US) findings of Fontan-associated liver disease (FALD) and to determine whether screening US examinations can identify FALD before biochemical hepatic dysfunction. MethodsThis retrospective study included 55 patients who underwent Fontan procedure over a 20-year period. Hepatobiliary US findings (n=55), CT or MRI findings (n=19), biochemical hepatic function tests (n=49), and histopathological results (n=4) were analyzed. Images were reviewed focusing on the hepatic parenchymal changes, presence of focal lesions, and signs of portal hypertension. ResultsHepatic parenchymal changes (either heterogeneous echotexture or surface nodularity) evident on US were present in 67% (37/55) and showed positive correlation with the Fontan duration. Hyper-echoic lesions were noted in 35% (19/55) and showed a predilection for multiplicity, small size, right lobe location, and irregular margin on high-frequency transducer. These lesions were not demonstrated by CT or MRI or by low-frequency transducer. Histopathological results of targeted biopsy for hyper-echoic lesions revealed lesser degree of patchy sinusoidal and portal fibrosis than seen in cases with surface nodularity. Abnormal parenchymal enhancement was commonly seen with CT or MRI in 63% (12/19) and hypervascular nodules in 21% (4/19). Most patients (82%, 40/49) showed normal biochemical hepatic function tests, despite the presence of hepatic parenchymal changes on imaging. ConclusionThe common US findings of FALD included heterogeneous parenchymal echotexture, surface nodularity, and hyper-echoic lesions. We suggest that hyper-echoic lesions without surface nodularity detected by high-frequency transducer may represent the early stage of fibrosis. US examination may be useful for identifying the progression of FALD before biochemical hepatic dysfunction.

Abstract WMP92: Location of Hemorrhage Predicts Hematoma Expansion and Poor Clinical Outcome

Background: Baseline volume, spot sign, and coagulation status all predict early hematoma expansion (HE) in intracerebral hemorrhage (ICH). However, the role of ICH location on HE remains unclear. We hypothesized that lobar-located ICH would facilitate HE as it provides a larger potential volume for expansion as compared to deep locations. However, due to the close proximity of critical structures and increased risk of ventricular rupture, we also hypothesized that deep ICH would have a paradoxically increased risk of mortality and morbidity. Our objective was to assess the effect of lobar vs. non-lobar hemorrhage on HE and clinical outcome. Methods: We analyzed data from the prospective multicentre PREDICT study where patients with ICH presenting to hospital under 6 hours of symptom onset received a baseline CT, CTA, 24 hour follow-up CT, and 90-d mRS. ICH location was categorized as lobar vs deep, and primary outcomes were significant HE (&gt;6mL) and poor clinical outcome (mRS &gt;3). Multivariable regression with stepwise selection was used to adjust for relevant covariates. Sensitivity analysis was conducted by expanding the inclusion criteria to include patients who died or were treated with Factor VIIa and/or surgery prior to follow-up CT. Results: Among 302 patients meeting the inclusion criteria, lobar hemorrhage was associated with increased hematoma expansion &gt;6mL (p=0.003), poor clinical outcome (p=0.011) and mortality (p=0.017). When adjusted for covariates, lobar hemorrhage independently predicted significant hematoma expansion (aOR 2.3 [95% CI: 1.2-4.4], p=0.02). Sensitivity analysis included a total of 353 patients and lobar location was no longer significantly associated with poor outcome (p=0.198). This appeared to be related to a higher proportion of IVH in the excluded population (33% Primary vs. 65% Excluded, p&lt;0.001). Conclusion: Lobar hemorrhage led to expansion and poor clinical outcome in the primary analysis population. Sensitivity analysis of the excluded population revealed that deep bleeds are associated with a higher degree of mortality and morbidity, likely due to a higher frequency of IVH. Our findings suggest that baseline ICH location should be considered for risk stratification algorithms.

Abstract 90: Cerebral Microbleeds in CADASIL: Influence of APOE Genotype and Hypertension

Introduction: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is a genetic disorder with an important predisposition for development of cerebral microbleeds (CMB). However, the relative impact of the two most common risk factors for CMB, hypertension and cerebral amyloid angiopathy, in CADASIL is uncertain. Hypothesis: We hypothesized that APOE (apolipoprotein E, an important predictor and correlate of cerebral amyloid angiopathy) genotype and hypertension influenced the presence and distribution of CMB in patients with CADASIL. Methods: CMB were identified as small (up to 10 mm) areas of signal void seen on 3.0T MRI susceptibility-weighted images. The locations of CMB were characterized as lobar, deep, and infra-tentorial. Results: In 83 patients with CADASIL (mean age 62.5 years), CMB were observed in 69.9% (58/83) of the total patient population. The most common areas of CMB were deep (57.8%, 48/83), lobar (50.6%, 42/83), and infra-tentorial location (38.4%, 33/83). Hypertension was found in 59% (49/83) of patients. APOE genotype frequencies were: ε2/ε3 9.6% (8/83); ε2/ε4 2.4% (2/83); ε3/ε3 57.8% (48/83); ε3/ε4 30.1% (25/83). Hypertension was associated with presence of CMB in lobar (p&lt;0.001), deep (p=0.035), and infra-tentorial locations (p=0.012). However, no significant associations were found between APOE genotype and presence of CMB in any location. Conclusions: In this cohort of CADASIL patients, hypertension but not APOE genotype predicted presence of CMB in all locations. These findings suggest that hypertension may amplify the arteriopathy of CADASIL in the development of CMB.

Abstract 43: Dementia After Spontaneous Intra-cerebral Hemorrhage

Background: Stroke and dementia are closely related but no prospective study ever focused on dementia in patients with intracerebral hemorrhage (ICH). Objective: To determine incidence, prognostic factors and possible mechanisms of post-ICH dementia in a large population of non-demented ICH patients over a long period of follow-up. Methods: Prospective cohort of consecutive adults with spontaneous ICH. Patients free of dementia and alive at 6 months were included. We studied clinical and neuroradiological (MRI) biomarkers with a prespecified subgroup analysis according to ICH location. Age-adjusted analyses were used to select variables (p&lt;0.1) included in multivariable models that took into account death as competing risk. Results: In a cohort of 218 ICH patients (108 males; median age 67.5, interquartile range (IQR) 55-76), 63 patients developed new onset dementia during a median follow-up of 5.4 years (IQR, 4.2-5.8). At 1 year after ICH, the overall incidence of dementia was 20% (95% CI 15-25). It differed between lobar ICH (n=77, 30% 95% CI 20-40) and non lobar ICH (n=141, 16% 95% CI 10-22). Prognostic factors of new onset dementia were lobar Iocation (Hazard Ratio (HR): 2.21; 95% CI 1.30-3.79), older age (HR: 1.06 per year; 95% CI 1.03-1.09), history of previous stroke or transient ischemic attack (HR: 2.56; 95% CI 1.42-4.61), higher NIHSS (HR: 1.03 per year; 95% CI 1.01-1.06), severe leucoaraïosis (HR: 2.87; 95% CI 1.63-5.07) and recurrent stroke during follow-up (HR: 3.22; 95% CI 1.27-8.15). Prognostic neuroradiological biomarkers were increasing cortical atrophy (HR: 2.7; 95% CI 1.7-4.3), presence of disseminated superficial siderosis (HR: 7.10; 95% CI 3.93-12.83), higher number of lobar cerebral microbleeds (HR: 3.40; 95%CI 1.87-6.18). Among lobar ICH, superficial siderosis was a strong predictor (HR: 6.74; 95% CI 3.32-13.68). Conclusion: The incidence of new onset dementia is high after ICH with a strong influence of lobar location. Among patients with lobar ICH, prognostic factors suggested a strong implication of underlying cerebral amyloid angiopathy that might predict future risk of dementia. Results of our study suggest that all prognostic factors of dementia are already present before the ICH occurs.

Molecular analysis of peripheral non-squamous non-small cell lung cancer sampled by radial EBUS.

Treatment optimization of non-squamous non-small-cell lung cancers (nonSq-NSCLC) relies on the molecular analysis of the tumour. We aimed to assess the predictive factors of molecular analysis feasibility (MAF) from samples of peripheral nonSq-NSCLC obtained by radial endobronchial ultrasound bronchoscopy (r-EBUS) and 1.5 mm microbiopsy forceps. We reviewed data from consecutive peripheral lung nodules sampled with r-EBUS between January 2012 and July 2014 at a single French University Hospital. nonSq-NSCLC were systematically analysed for EGFR, KRAS, ALK, HER2, PI3K and BRAF throughout the study, and c-MET and ROS1 alterations for the last 10 months. Of 111 nonSq-NSCLC diagnosed by r-EBUS (113 procedures, mean nodule diameter 28 ± 15 mm), 88 were analysed for EGFR and ALK, 87 for KRAS, 86 for HER2, PI3K and BRAF and 14 for c-MET. Forty-one mutations were identified (23 KRAS, 10 EGFR, 2 BRAF, 1 HER2 and 5 ALK rearrangements). Four c-MET overexpressions were noted. MAF rose from 67% for the first 57 procedures to 89% for the last 56 procedures (P = 0.02) likely due to a higher number of biopsies performed (2 ± 1 vs 3 ± 2, P = 0.005). Upper or middle lobe location (OR 1.19, 95% CI: 1.02-1.38, P = 0.03), and at least three biopsies (OR 1.20, 95% CI: 1.04-1.40, P = 0.02) were predictive factors of MAF. Percentage of tumour cells, size of lesion and distance to the pleura did not correlate with MAF. Multi-gene molecular analysis could be performed in nearly 80% of paraffin-embedded biopsies or smear specimens sampled by r-EBUS assisted bronchoscopy of peripheral tumoral lung nodules.

Congenital bilateral perisylvian syndrome: a rare cause of epilepsy

Congenital bilateral perisylvian syndrome (CBPS) is an entity proven or diagnosed on basis of neuroimaging in the form of MRI (Magnetic Resonance Imaging). A case with classical triad of fascio- masticatory diplegia, epilepsy and mental retardation has been seen. We report a case of a 6 years old male child on intermittent treatment for seizures since 6 months presenting to us with abnormal movement, recurrent spitting and drooling of saliva with slurring of speech. Diagnosed on MRI with involvement of perisylvian location in temporal lobe. The etiology of epilepsy was justified and symptomatically treated.

Distant Multifocal Bony Metastasis of a Grade II Meningioma: Case Report

Introduction Meningioma is the most frequent neoplasm of the central nervous system, accounting for nearly one-third of all intracranial tumors. The vast majority are benign and cured by surgical resection. Grade II meningiomas may show local invasion involving the brain, intracranial venous channels, bones, soft tissue and paranasal sinuses. Distant metastasis, on the other hand, is quite rare. Case Presentation We report distant, multifocal bony metastasis of an atypical meningioma, World Health Organization grade II, from a primary occipital lobe location in a patient who initially underwent stereotactic radiosurgery followed by surgical resection 4 years prior. The patient presented clinically with pain in the lower back and gluteal region. Distant metastases were noted radiologically in the lumbar spine, pelvis, and femur and were confirmed pathologically following biopsy. Conclusion Metastasis from meningiomas is exceedingly uncommon. In the present case, hematogenous spread to the lumbar spine, pelvis, and femur may have occurred due to a residual nodular remnant within the superior sagittal sinus.

Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry.

Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.