Multimodal Work-up Research Articles

Other causes of neurocognitive impairment than covert hepatic encephalopathy (CHE) are very frequent, either alone or associated with CHE, in cirrhotic patients with cognitive complaints.

Although it is well admitted that cirrhotic patients display various causes of neurocognitive impairment (NI) hampering the diagnosis of covert hepatic encephalopathy (CHE), those are almost never investigated per se. The aims of this study were, in cirrhotic patients displaying cognitive complaints explored by a complete multimodal work-up, to assess: (1) the prevalence of CHE and/or that of other causes of NI and (2) their outcomes, according to the cause of NI. Prospective cohort of cirrhotic patients referred in a dedicated clinic because of cognitive complaints. Work-up included a complete neuropsychological assessment, electroencephalogram (EEG) and brain magnetic resonance imaging with spectroscopy. The diagnosis of CHE was made by an adjudication committee involving the physicians/neuropsychologist. One hundred and twenty-three patients were included (alcohol/MASLD/virus in 63/53/14%, MELD = 11). Sixty-six per cent of them were diagnosed with CHE; among them, 73% exhibited also other causes of NI, mainly cerebrovascular diseases/psychiatric. Among patients without CHE, 48% and 59% displayed pathological Psychometric Hepatic Encephalopathy Score and animal naming test, respectively. Clinical improvement was observed in 77% of the patients re-evaluated after specific management. CHE, but not the other causes of NI, was independently associated with OHE occurrence. Other causes of NI than CHE are frequent in patients with cirrhosis, and not ruled-out by the classical tests dedicated to CHE. Prognosis was influenced by the cause of NI. The management of patients even without CHE led to clinical improvement, underlining the need for a multifaceted approach of cirrhotic patients with cognitive complaints.

Dysphagia and oesophageal dilation in giant hiatus hernia: angulation of the gastro-oesophageal junction or achalasia?

The co-existence of achalasia and large para oesophageal hernia (PEH) is uncommon. The anatomical disruption of the GOJ mechanism by hiatal herniation may result in chronic angulation and secondary partial oesophageal obstruction. A unique case is described where the diagnostic uncertainty of coexistant achalasia and PEH with angulation causing chronic oesophageal obstruction existed. This case highlights the importance of multimodality workup of oesophageal disorders utilising endoscopy, fluoroscopy and manometry. Accurate identification of physiological abnormalities allowed appropriate design of operative intervention.

Early Biological Valve Failure: Structural Valve Degeneration, Thrombosis, or Endocarditis?

Biological valve failure (BVF) is an inevitable condition that compromises the durability of biological heart valves (BHVs). It stems from various causes, including rejection, thrombosis, and endocarditis, leading to a critical state of valve dysfunction. Echocardiography, cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging play pivotal roles in the diagnostic multimodality workup of BVF. By providing a comprehensive overview of the pathophysiology of BVF and the diagnostic approaches in different clinical scenarios, this review aims to aid clinicians in their decision-making process. The significance of early detection and appropriate management of BVF cannot be overstated, as these directly impact patients' prognosis and their overall quality of life. Ensuring timely intervention and tailored treatments will not only improve outcomes but also alleviate the burden of this condition on patients' life. By prioritizing comprehensive assessments and adopting the latest advancements in diagnostic technology, medical professionals can significantly enhance their ability to manage BVF effectively.

MicroRNA profiling of cerebrospinal fluid from dogs with steroid responsive meningitis-arteritis and meningoencephalitis of unknown origin.

Non-infectious inflammatory diseases of the central nervous system in dogs, such as steroid responsive meningitis-arteritis (SRMA) and meningoencephalitis of unknown origin (MUO), represent a common clinical challenge that needs extensive and multimodal work-up to reach a presumptive diagnosis. Both diseases are presumably caused by dysregulations of the immune system, but further research is needed in order to understand the molecular mechanisms behind each disease and to optimize treatment. By next-generation sequencing and subsequent quantitative real-time PCR (qPCR) verification, we designed a prospective case-control pilot study to analyze the small RNA profiles of cerebrospinal fluid from dogs suffering from MUO (N = 5), dogs suffering from SRMA (N = 8), and healthy dogs (N = 5) presented for elective euthanasia used as the Control group. Our results showed an overall enrichment in Y-RNA fragments across all samples, followed by microRNAs (miRNAs) and ribosomal RNAs as the major findings. Additional traces of short RNA reads mapped to long non-coding RNAs and protein-coding genes were also found. From the detected canine miRNAs, miR-21, miR-486, miR-148a, miR-99a, miR-191 and miR-92a were among the most abundant. Dogs with SRMA showed higher differences in miRNA abundance than dogs with MUO when compared to healthy dogs, and miR-142-3p was consistently detected as differentially upregulated in both diseases, although at a low concentration. Moreover, miR-405-5p and miR-503-5p showed different profiles between SRMA and MUO dogs. Subsequent qPCR analyses confirmed miR-142-5p, miR-191-5p and miR-92a-3p as significantly upregulated miRNAs in dogs with SRMA and/or MUO. Cerebrospinal fluid is a challenging biological material to use for profiling miRNAs due to the low content of circulating RNAs. Despite this, we could confirm several miRNAs being differentially abundant when comparing healthy dogs and dogs with MUO and SRMA, respectively. The results of this study indicate a potential role of miRNAs in the underlying molecular mechanisms of these diseases and establish the basis for further studies.

Role of 18F-FDG PET-CT Imaging in a Patient with Renal Ewing’s Sarcoma: A Rare Case Report

Ewing's sarcoma (ES) is a bone-related tumor that typically affects young children and adolescents. Primary renal Ewing sarcoma (RES) is extremely rare. Sources of Ewing sarcoma in the kidney include invagination or migration of neural crest cells to the kidney. Here, a case of a young adult male with renal Ewing sarcoma is presented. A 28-year-old male presented with nausea, hematuria, and left flank pain for seven days with an unremarkable previous medical history. An ultrasound and CT scan revealed a massive lobulated mass in the upper and midsection of the left kidney. A radical nephrectomy was done. Histopathology and immunohistochemistry revealed Ewing’s sarcoma/primitive neuroectodermal tumor. The chest X-ray and chest CT scan were negative for metastasis. Initial staging was T2bNxM0. Before starting further treatment, the patient was advised to undergo a fluorine-18 FDG (fluorodeoxyglucose) positron emission tomography (F-18 FDG PET-CT) scan for the detection of occult metastases. A F-18 FDG PET-CT scan revealed peritoneal seeding, skeletal and abdominal lymph node metastases. A multimodality workup is essential for proper management of Ewing sarcoma of the kidney due to its rarity and unusual location. F-18 FDG PET-CT plays a critical role in the detection of occult metastases, staging, restaging, and treatment planning in patients with RES. Bangladesh J. Nuclear Med. 26(1): 54-57, 2023

Developmental Deconvolution for Classification of Cancer Origin.

Here we map the developmental trajectories of tumors. We deconvolute tumor transcriptomes into signals for mammalian developmental programs and use this information to construct a deep learning classifier that outputs tumor type. We apply the classifier to CUP and reveal the developmental origins of patient tumors. See related commentary by Wang, p. 2498. This article is highlighted in the In This Issue feature, p. 2483.

Abstract 4100: Developmental deconvolution for classification of cancer origin

Abstract Cancer is a disease manifesting in abrogation of developmental programs, and malignancies are namedbased on their cell or tissue of origin. However, a systematic atlas of tumor origins is lacking. Here we map the single cell organogenesis of 56 developmental trajectories to the transcriptomes of over 10,000 tumors across 33 cancer types. We use this map to deconvolute individual tumors into their constituent developmental components. Based on these deconvoluted developmental programs, we construct a Developmental Machine Learning Perceptron (D-MLP) classifier that outputs cancer origin. The D-MLP classifier (ROC-AUC: 0.974 for top prediction) outperforms classification based on expression of either oncogenes or highly variable genes. We analyze tumors from patients with cancer of unknown primary (CUP), selecting the most difficult cases where extensive multimodal workup yielded no definitive tumor type. D-MLP revealed insights into developmental origins and diagnosis for most patient tumors. Our results provide a map of tumor developmental origins, provide a tool for diagnostic pathology, and suggest developmental classification may be a useful approach for otherwise unclassified patient tumors. Citation Format: Enrico Moiso, Alexander Farahani, Hetal Marble, Austin Hendricks, Samuel Mildrum, Stuart Levine, Jochen Lennerz, Salil Garg. Developmental deconvolution for classification of cancer origin [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4100.

MP52-08 ARTIFICIAL URINARY SPHINCTER CUFF DOWNSIZING IMPROVES CONTINENCE AND PATIENT SATISFACTION IN CASES OF SUB-CUFF ATROPHY

You have accessJournal of UrologyCME1 May 2022MP52-08 ARTIFICIAL URINARY SPHINCTER CUFF DOWNSIZING IMPROVES CONTINENCE AND PATIENT SATISFACTION IN CASES OF SUB-CUFF ATROPHY Kevin Krughoff, Brent D. Nosé, and Andrew C. Peterson Kevin KrughoffKevin Krughoff More articles by this author , Brent D. NoséBrent D. Nosé More articles by this author , and Andrew C. PetersonAndrew C. Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002627.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The management of suspected artificial urinary sphincter (AUS) sub-cuff atrophy remains controversial and clinical outcomes remain underreported. Our objective was to examine the impact of cuff downsizing on patient reported outcomes and pad use in cases of sub-cuff atrophy. METHODS: We reviewed our prospectively collected, institutional approved QI database from 2011 to 2021. IRB approval was obtained for the analysis. At our institution, the AUS is routinely filled with contrast solution and imaged radiographically upon initial activation for a baseline. This allows for better delineation between device failure or sub-cuff atrophy during standard multimodal workup of recurrent urinary incontinence with serial AP Pelvis radiography. Patients are seen on a routine basis following activation. Sub-cuff atrophy was diagnosed with serial AP pelvis films indicating atrophy, cystoscopy, assessment of symptom scores and pad use, and history and physical examination. Patients with post-prostatectomy incontinence who underwent cuff downsizing after the diagnosis of sub-cuff atrophy were included for analysis. Repeated measures T-tests were used to assess change in validated survey instruments, subjective outcomes measures and pad use. RESULTS: Over this time-period, 842 AUS devices were placed, 623 new and 219 revisions. Of these, 30 underwent cuff downsizing following a diagnosis of sub-cuff atrophy as determined by the appearance of more fluid in the cuff versus baseline on AP pelvis film, cystoscopy with incomplete coaptation, patient interview and questionnaires, and evaluation of number pads used per day. The initial AUS was in place for a median of 668 days (292, 1601) prior to the diagnosis of sub-cuff atrophy. Median follow up duration after cuff downsizing was 3561 days (2247, 4704). At time of most recent assessment, 23 (73.3%) of downsized cuffs remained in place, 2 (6.6%) were revised for mechanical failure, 2 (6.6%) for further atrophy and 3 (10.0%) for erosion. Following downsize, 96.7% reported subjective improvement and 92.0% experienced a decrease in pad count, with a median decrease of 2 and mean decrease of 2.21 (± 1.45) pads per day (p<0.01). Of those who completed the AUA Symptom Score before and after downsize, 82% experienced an improvement on the bother index score (mean decrease 1.63 ± 1.74, median 1, p=0.01). CONCLUSIONS: Cuff downsizing improves continence control and patient satisfaction in cases of multimodal diagnosed sub-cuff atrophy. Source of Funding: Boston Scientific Fellowship Grant © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e889 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Krughoff More articles by this author Brent D. Nosé More articles by this author Andrew C. Peterson More articles by this author Expand All Advertisement PDF DownloadLoading ...

Prenatal Diagnosis, Multimodality Workup and Postnatal Follow Up of Fetal Pancake Kidneys: A Rare Case Report

Prenatal Diagnosis, Multimodality Workup and Postnatal Follow Up of Fetal Pancake Kidneys: A Rare Case Report

Pulmonary Artery Sarcoma: Value of Dual-Energy CT (DECT)-Based Iodine Quantification on Multimodality Workup

Pulmonary Artery Sarcoma: Value of Dual-Energy CT (DECT)-Based Iodine Quantification on Multimodality Workup

Automated ictal EEG source imaging: A retrospective, blinded clinical validation study

ObjectiveEEG source imaging (ESI) is a validated tool in the multimodal workup of patients with drug resistant focal epilepsy. However, it requires special expertise and it is underutilized. To circumvent this, automated analysis pipelines have been developed and validated for the interictal discharges. In this study, we present the clinical validation of an automated ESI for ictal EEG signals. MethodsWe have developed an automated analysis pipeline of ictal EEG activity, based on spectral analysis in source space, using an individual head model of six tissues. The analysis was done blinded to all other data. As reference standard, we used the concordance with the resected area and one-year postoperative outcome. ResultsWe analyzed 50 consecutive patients undergoing epilepsy surgery (34 temporal and 16 extra-temporal). Thirty patients (60%) became seizure-free. The accuracy of the automated ESI was 74% (95% confidence interval: 59.66–85.37%). ConclusionsAutomated ictal ESI has a high accuracy for localizing the seizure onset zone. SignificanceAutomating the ESI of the ictal EEG signals will facilitate implementation of this tool in the presurgical evaluation.

Primary Intrathoracic Sarcomas: A Review of Cross-sectional Imaging and Pathology.

The most common sarcomas in the thorax are metastasis from an extrathoracic primary malignancy. Primary intrathoracic sarcomas are rare albeit aggressive malignancies that are diagnosed on histopathology. Although a few imaging characteristics have been described that are common to sarcomas, it is still a diagnosis of exclusion as other tumors are much more common. Like elsewhere, primary thoracic sarcomas are also classified according to their histologic features. They are a rare group of tumors that can arise from the mediastinal structures, lung, pleura, or chest wall. On imaging, differentiating these from more common malignancies like lung cancer is difficult and often requires multimodality workup and tissue sampling. A few sarcomas are very specific to their locations, such as angiosarcoma in the right atrium, leiomyosarcoma in the pulmonary artery, where imaging has high accuracy for the diagnosis. Despite being nonspecific in a majority of cases, imaging plays a pivotal role in determining the organ of origin, tumor extent, invasion of adjacent structures, and thus help to assess the surgical resectability. Although sarcomas arising from chest wall are the most common primary sarcomas in the chest, they are excluded from this review to focus only on primary intrathoracic sarcomas. The article provides a comprehensive imaging and pathology review of the rare primary intrathoracic sarcomas, including but not limited to angiosarcoma, Kaposi sarcoma, fibrosarcoma, malignant transformation of fibrous tumor of pleura, sarcomatoid mesothelioma, leiomyosarcoma, and malignant small round blue cell tumors.Key points:Primary intrathoracic sarcomas are rare but clinically important.Imaging helps to determine local extent, invasion, metastases and appropriate site/mode of biopsy.Role of pathology is paramount in diagnosis and guiding treatment based on immunogenetic/molecular typing.

Risk of malignancy in Caroli disease and syndrome: A systematic review.

BACKGROUNDCongenital intrahepatic bile duct dilatation without fibrosis is called Caroli disease (CD), and is called Caroli syndrome (CS) when it has fibrotic and cirrhotic liver morphology. The development of intrahepatic carcinoma is described in both conditions, but the reported incidence varies extensively. Potential risk factors for the malignant transformation were not described. Furthermore, conservative or surgical treatment is performed depending on the extent of cystic malformation, hepatic dysfunction and structural hepatic changes, but little is known about which treatment should be offered to patients with CD or CS and cancer.AIMTo further investigate the malignant transformation in these conditions.METHODSA systematic review of the current literature until January 2019 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A search using Medline (PubMed) was performed using a combination of Medical Subject Headings terms “caroli disease”, “caroli syndrome”, “tumor”, “malignant”, and “cholangiocarcinoma”. Only human studies published in English were used for this systematic review. The following parameters were extracted from each article: year of publication, type of study, number of patients, incidence of malignant tumor, duration of symptoms, age, sex, diagnostics, identification of tumor, surgical therapy, survival and tumor recurrence.RESULTSTwelve retrospective studies reporting the courses of 561 patients (53% females) were included in this systematic review. With a mean age of 41.6 years old (range 23 to 56 years old), patients were younger than other populations undergoing liver surgery. Depending on the size of the study population the incidence of cholangiocarcinoma varied from 2.7% to 37.5% with an overall incidence of 6.6%. There were only few detailed reports about preoperative diagnostic work-up, but a multimodal work-up including ultrasound of the liver, computed tomography, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography was used in most studies. Disease duration was variable with up to several years. Most patients had episodes of cholangitis, sepsis, fever or abdominal pain. Tumor detection was an incidental finding of the surgical specimen in most cases because it is currently often impossible to detect tumor manifestation during preoperative diagnostics. Liver resection or liver transplantation was performed depending on the extent of the biliary pathology and additional alterations of the liver structure or function. No postoperative adjuvant chemotherapy was reported, but chemotherapy was administered in selected cases of tumor recurrence. Overall survival rates after one year were low at 36% and a high recurrence rate of up to 75% during the observation period.CONCLUSIONOnly few retrospective studies reported a low tumor incidence. Despite the high rate of mortality and tumor recurrence, definite surgical treatment should be offered as soon as possible.

Multimodal Presurgical Evaluation of Refractory Localization-Related Epilepsy Involving Mesial Temporal Lobe Structures

Abstract INTRODUCTION Localization-related epilepsy frequently involves mesial temporal lobe structures (MTLS), but sometimes presurgical workup can be confusing since shortage of definite structural lesional evidence or inconsistency among multimodal tools. Occasionally invasive workup is applied. This study evaluates the application of multimodal workup in surgical strategy making of localization-related epilepsy involving MTLS. METHODS Our study includes patients with significant or subtle MTLS abnormality (or magnetic resonance imaging (MRI) negative) in 3.0T MRI and then underwent resective surgeries encompassing MTLS. In addition to conventional workup tools, accurate EEG source imaging (ESI) technique based on individual head models is available. Patients accepted either 1-stage resective surgeries or staged surgeries (SEEG implantation + stage-2 resective surgeries). Contributions of structural MRI, fluorodeoxyglucose-positron emission tomography (FDG-PET), accurate ESI, and ictal EEG to surgical strategies were evaluated by criteria defining epileptogenic zone (resective scope in cases with good outcome). RESULTS Thirty-five patients who achieved Engel grade I + II outcome after resective surgeries were included. All together, 68.6% cases showed ESI sources totally falling into resective scope. 42.9% ictal EEG estimates, 57.1% PET focal hypometabolistic regions, 74.3% MRI structural lesions fitted the resective scope/side. In total, 75% 1-stage cases showed ESI sources being confined in MTLS region, while PET showed focal hypometabolism in 66.7% and MRI indicated single MTLS lesions (including subtle ones) in 79.2% cases. In total, 54.5% ESI sources and 63.6% MRI abnormality (single, including subtle ones) in staged cases showed complete concordance with SEEG findings. In subtle lesional/MRI negative cases, ESI generated sources confined within MTLS in 77.8% cases, while PET estimates are focally localizing in 44.4% cases and 55.6% showed subtle MRI lesions which were firstly diagnosed “negative.” CONCLUSION Multimodal noninvasive workup are contributable to help decide strategy of 1-stage resective surgeries and SEEG plans in localization-related epilepsy. High-quality structural MRI, accurate ESI technique based on scalp EEG as well as FDG-PET are key to presurgical planning of epilepsy involving MTLS.

A multimodality work‐up of patients with Hypereosinophilia

The work-up of patients with hypereosinophilia (HE) is complex. Following the recently revised World Health Organization criteria, we retrospectively reviewed 125 patients who were referred to us to exclude a neoplastic cause of HE (2003-2016). The clinical laboratory work-up confirmed secondary HE in 25 (20%) patients; myeloid/lymphoid neoplasms with rearrangements of PDGFRA (n = 9) or PDGFRB (n = 2) (9%); HE associated with a well-defined myeloid neoplasm in 8 (6%); and abnormal bone marrow and/or molecular genetic abnormalities consistent with chronic eosinophilic leukemia (CEL), not otherwise specified (NOS) in 21 (17%) patients. For the remaining 60 (48%) patients, a specific diagnosis was not identified, and 56 patients had HE related findings consistent with idiopathic hypereosinophilic syndrome (HES), while 4 patients who were asymptomatic. With a median follow up of 35.3 months (range, <1-104), patients with CEL, not otherwise specified (NOS) had a median OS of 26.1 months, significantly inferior to patients with idiopathic HES (not reached, P < .01). Thus, our experience in a single tertiary cancer center shows that the work-up of HE following WHO recommendations requires a multimodality-based approach; and a correct diagnosis determines risk stratification and proper patient management. However, the causes of HE remain unknown in approximately half of referred patients, indicating the need for further studies.

The Necessity of Multimodality Workup in Cervical Spine Injury

The Necessity of Multimodality Workup in Cervical Spine Injury

Indolent systemic mastocytosis associated with light chain deposition disease

Systemic mastocytosis (SM) is characterized by infiltration of neoplastic mast cells in one or more organ systems. SM in association with plasma cell dyscrasia is very rare. We report a first case of indolent SM (ISM) associated with light chain deposition disease (LCDD) in a kidney biopsy from a 59-year-old female presenting with skin rash, elevated serum creatinine, hematuria and mild proteinuria. Subsequent workup demonstrated IgG kappa monoclonal protein in serum and urine. A bone marrow biopsy revealed neoplastic mast cells involving bone marrow without evidence of clonal myeloid or lymphoid proliferation. Kidney biopsy demonstrated modest mesangial expansion detected by light microscopy and unequivocal evidence of monoclonal kappa light chain deposition within glomerular capillaries, tubular basement membranes and vascular walls detected by immunofluorescence and/or electron microscopy, along with equivocal evidence of light chain cast nephropathy. Despite treatment with bortezomib and dexamethasone, her renal function was progressively declined over the next 6 months. This case is a reminder that SM can coincide with LCDD, which requires clinical suspicion and multimodality workup on a kidney biopsy including immunofluorescence and electron microscopy to reach the correct diagnosis.

Assessment of Lumbar Fusion: Importance of Dynamic Plain Standing X-rays

a c V g m b 57-year-old woman sustained an unstable flexionistraction fracture of the lumbar spine. She underwent urgical stabilization at another institution. This enailed a staged anterior and posterior approach with inerbody fusion of L1-L2, L3-L5 and posterior fusion and nstrumentation of L1-L5. There was initial improveent of her symptoms, but she later developed recurrent nset of back pain that was activity-related and imroved with rest. She had no fever, chills, nausea, vomting, weight change, or bowel or bladder dysfunction. n examination, she was neurologically intact with full otor strength and normal sensation. Range of motion f the lumbar spine was reduced, which accentuated her ack pain. The presence of severe persistent back pain along with ractured spinal implants at L2-L3 on plain x-rays reulted in the presumed diagnosis of a pseudarthrosis (A, nteroposterior, B, lateral). Nonunion of the fusion asses was not evident. Subsequent evaluation and exensive multimodality workup at several institutions inluding oblique x-rays, CT scan (C, sagittal; D, axial), nd MRI with gadolinium demonstrated bridging bone nd an apparent solid arthrodesis on multiple views. T-guided biopsy, bone scan, and laboratory blood ork did not reveal any evidence of a tumor or infection. ecause of a negative workup for evidence of infection, umor, or stenosis, combined with evidence of a solid usion, she was referred to us for evaluation. Simple tanding flexion-extension x-rays (E, flexion; F, extenion) revealed obvious motion at L2-L3 and motion at he fractured implant, confirming the pseudarthrosis. Lumbar fusion is a commonly performed spine surery, increasing in rate in the past decade, and often nvolving a multidisciplinary surgical team. The deciion to undergo revision surgery for persistent back pain fter spinal fusion is a challenge. The main goal is to stablish a diagnosis to develop a treatment plan. The ifferential diagnosis includes pseudarthrosis, infection, umor, stenosis, or unstable fracture. The evaluation hould include a careful history specifically for “red flag” s

Multimodality Imaging in a Depressed Patient with Violent Behavior and Temporal Lobe Seizures

Patients suffering from epilepsy commonly experience behavioral symptoms. Behavioral manifestations are especially prevalent in patients with seizures originating in the limbic system. This case report illustrates how an objective, multimodality work-up can guide the clinician in the diagnosis and the treatment of a patient with a complex presentation. After the discontinuation of some medications, the patient underwent a multimodality work-up that consisted of MRI, SPECT, and conventional and quantitative EEG (LORETA). In this case, the functional imaging studies showed a convergence of findings across the three modalities: MRI, SPECT and qEEG. Because of these findings, we supported more aggressive treatment of the seizure disorder. Ultimately this treatment resulted in resolution of the aggression and the depression. In summary, when applied routinely, a comprehensive, systematic, diagnostic approach will minimize treatment false starts and failures, may reduce costs, and also, potentially decrease the severity and the duration of symptoms.