Repeated Imaging Studies Research Articles

Digital cholangioscopy: the diagnostic yield and impact on management of patients with biliary stricture

:Objectives: Biliary strictures frequently present a diagnostic challenge. The aim of this study was to evaluate the impact of digital single-operator cholangioscopy (DSOC) on subsequent treatment of patients with biliary stricture.Methods: Consecutive patients undergoing DSOC for biliary stricture were enrolled. Gold standard for final diagnosis included histology from surgical resection. In patients without surgery, clinical evaluation methods and repeated imaging studies were used for comparison of DSOC findings and final diagnosis. Patients were followed-up prospectively focusing on subsequent treatment.Results: Among 30 enrolled patients, final diagnosis was malignant in 13 (43%) and benign in 17 (57%). The sensitivity and specificity of visual impression in diagnosing malignant stricture were 100% (95% CI: 75 − 100) and 76% (95% CI: 50 − 93), respectively. The sensitivity and specificity for biopsy were 92% (95% CI: 62 − 100) and 100% (95% CI: 78 − 100), respectively. One (3%) case of complicating cholangitis with fatal outcome occurred. Final treatment included surgery in 7 (23%), endoscopy in 18 (60%) and chemotherapy in 3 (10%) of patients.Conclusions: In this study, favorable operating characteristics of DSOC were confirmed. Absolute negative predictive value of visual impression provided reassurance to patients with benign strictures who avoided unnecessary surgery in 53%. One (3%) case of cholangitis with fatal outcome occurred.

Simultaneous Extrahepatic Portal and Iliac Veins Thrombosis After Abdominal Surgery - A Case Report and Review of Literature

Abstract Introduction: Extrahepatic portal vein thrombosis (EPVT) is the most frequent cause that leads to portal hypertension in non-cirrhotic patients. This condition is related to systemic and local risk factors (such as inflammatory lesions, injuries to portal venous system by surgery, vascular procedures). Case presentation: A case of extended extrahepatic portal vein thrombosis and simultaneous thrombosis of left common iliac vein and inferior vena cava, appeared after abdominal surgery in a hypertensive, diabetic, 50 y.o. man is presented. An acute episode of abdominal pain was interpreted as an emergency and a surgical (initially laparoscopic and then open) procedure was planned in order to perform an appendectomy. Discharge diagnosis was hemoperitoneum secondary to iatrogenic rupture of sigmoid mesocolon provoked by trocar manipulation. Repeated imaging studies performed later revealed the thrombosis of portal vein with extension into right portal branch associated with superior mesenteric thrombosis and free-floating thrombus into left common iliac vein extended towards inferior vena cava. Surgical manoeuvres are considered as triggers of these thrombotic events. After 4 weeks of parenteral anticoagulation a partial recanalization of thrombi was identified, without bleedings. Conclusions: Acute EPVT needs a carefully management. Case is linked to abdominal surgery and requires prolonged anticoagulation related to simultaneous portal and iliac vein thrombosis. Associated conditions (hypertension and diabetes mellitus) must have an appropriate approach. After our knowledge this is the first case published in literature.

Peppermint Oil Toxicity: Good for Your Breath but Can Be Bad for Your Bowels

Peppermint oil, ingested in excess, has been noted to cause generalized gastrointestinal symptoms including nausea, bloating, abdominal pain, and diarrhea. While the mechanism remains unknown, this rare case highlights peppermint oil toxicity inducing gastrointestinal symptoms that mimic IBD. 56 year-old female presented to GI clinic after three months of non-bloody diarrhea and diffuse abdominal pain. Patient underwent diagnostic colonoscopy showing inflammatory polyps in the proximal colon and diagnosed with indeterminate colitis. She was started on mesalamine for the colitis with no improvement in symptoms. Further testing was performed, including ESR, CRP, and fecal calprotectin drawn which were not elevated. Stool studies for infectious colitis were obtained and found to be negative. She also tried various dietary modifications, including lactose-free and gluten-free diets, with no help. On further questioning in clinic, the patient revealed she has a phobia regarding bad breath and consumes 30 to 40 peppermint Altoids every day, a source of peppermint oil. The patient was advised to abstain from ingesting any product which contained peppermint oil. Follow-up two weeks later by telephone, her abdominal pain and frequency of bowel movements had significant improved. This case highlights the importance of thorough history taking to avoid unnecessary initiation of medications, unnecessary escalation in medical therapy, repeated imaging studies, or multiple endoscopic investigations. This case represents a very rare condition of peppermint oil toxicity that mimics symptoms of IBD. Simple dietary modification with peppermint oil elimination resulted in alleviation of symptoms.

Lifetime Radiation Exposure in Patients with Recurrent Nephrolithiasis.

Patients presenting with nephrolithiasis often undergo repeated imaging studies before, during, and after management. Considering the significant risk of stone recurrence in primary stone-formers, repeated imaging studies are not uncommon. Cumulative effects of ionizing radiation exposure from various imaging studies could potentially increase the risk for developing cataracts and solid malignancies in urolithiasis patients. Therefore, practitioners planning or performing imaging studies with ionizing radiation are compelled to keep radiation exposure to humans and the environment as low as possible, thus strictly adhering to the ALARA (As Low as Reasonably Achievable) principles. This chapter will review the latest literature on lifetime radiation exposure of nephrolithiasis patients and present the latest recommendations in minimizing radiation exposure to them pre-, intra-, and postoperatively. For patients presenting with acute renal colic, especially those with body mass index of <30, low-dose noncontrast computed tomography is the current gold standard of imaging. Patients with opaque stones are followed with ultrasonography (US) and plain radiography (kidney, ureter, and bladder or KUB). Intraoperatively, pulsed fluoroscopy could be used to significantly reduce radiation during ureteroscopy and percutaneous nephrolithotomy. Immediately postoperatively and in the long term, US and KUB could be used to follow up patients with nephrolithiasis. Only symptomatic patients suspected of ureteral stricture should obtain tri-phasic CT urography. Following these latest imaging guidelines from the American Urological Association will dramatically reduce lifetime radiation exposure to patients with nephrolithiasis.

Overimaging and the “Found Down” Patient: An Opportunity to Set the Standard of Care

I recently read a head CT study that turned out to be the 100th head CT study performed on a specific patient at our institution in the past decade. Although this sounds extreme, those of us who work in the emergency setting have unfortunately periodically come across this kind of patient: someone whose regular daily routine involves drinking to the point of unconsciousness, stumbling outside, being “found down,” by the police or other good Samaritans, and being brought to the emergency department (ED). The ED physicians understandably cannot obtain a useful history or perform a meaningful neurologic examination because the patient is heavily intoxicated, and they cannot definitively exclude some occult intracranial injury, so they order a head CT, which typically shows the chronic changes of habitual heavy alcohol use, maybe some small-vessel ischemic changes, but nothing acutely treatable. The radiologists thereafter softly scold their ED colleagues in the impression of the report, noting the extreme number of repeat imaging studies for this individual, and suggest that the ED use “risk stratification” for future imaging given the cumulative risk of radiation. And the pattern repeats. Arbitrary Radiation Dose “Limits” Must Not Set Standard of CareJournal of the American College of RadiologyVol. 15Issue 3PreviewIn his recent opinion piece, “Overimaging and the ‘Found Down’ Patient: An Opportunity to Set the Standard of Care,” Dr Mezrich poses the question, “When is a head CT scan one too many?” [1]. He specifically discusses patients who are brought to the emergency department after being found unresponsive (often due to drug or alcohol use), but the topic is applicable to any discussion of patients who receive multiple imaging examinations. Full-Text PDF

Subclinical enthesitis in nail psoriasis patients: a case-control study.

Patients with nail psoriasis have a higher prevalence of psoriatic arthritis; however, the pathogenetic relationship between these two disorders is as yet unclear. Entheses have been suggested as disease epicenter, which might explain the pathogenesis on an anatomical level. To contribute to the elucidation of the hypothesis as regards the anatomical link between nail psoriasis and psoriatic arthritis, with the extensor enthesis of the distal interphalangeal joint as the epicenter. We conducted a cross-sectional cohort study, visualizing the distal interphalangeal (DIP) joints entheses of patients with fingernail psoriasis (n = 54), psoriasis patients without nail involvement (n = 32), and healthy controls (n = 32) using three-dimensional ultrasound. Patients with nail psoriasis underwent repeat imaging studies after one year. Individuals with nail psoriasis had significantly thicker radial entheses than psoriasis patients without nail involvement. However, there were no significant differences in entheseal thickness between adjacent nails that were affected and those that were not (1.297mm vs. 1.253mm, p = 0.13). Follow-up after one year showed no significant differences in entheseal thickness in correlation with nail psoriasis activity. The present study provides evidence for subclinical enthesitis at the level of the DIP joint in patients with nail psoriasis. However, an anatomical correlation between nail psoriasis and psoriatic arthritis could not be confirmed.

Post Renal Transplant Surgical Complications; MRI Standard Applications and Diagnostic Outcomes

Objective: Fast MR imaging sequences together with paramagnetic contrast agents, offer multiple advantages in the assessment of renal function. It provides cross sectional and vascular information without the risk of ionizing radiation, iodinated contrast or arterial catheterization. Post transplantation complications can be grouped as surgical or medical. Immediate surgical complications include renal artery thrombosis or stenosis, urinary leak or lymphocele. Renal allograft frequently require repeated imaging studies during the immediate post-operative period and various times thereafter, when renal function is compromised. Background: End stage renal disease is common and can result from a variety of diseases. Kidney transplantation from living-related donors offered the best prognosis. Imaging modalities that are currently used to evaluate transplanted kidneys are ultrasound (US), computed tomography (CT), scintigraphy, intravenous urography (IVU), contrast angiography, and magnetic resonance imaging (MRI). Methods: This study was conducted on 181 renal transplant recipients. Recipients were 139 males and 42 females. Their age ranged from 20 to 58 years (mean age 39 years). The patients underwent clinical assessment, Laboratory investigations, and different Radiological imaging procedures as: I- Gray scale and color Doppler ultrasonography. II- Magnetic Resonance Imaging. 3D Gd-enhanced MRA. MR Urography. Selective IA-DSA of the graft artery. III- Percutaneous catheter nephrostomy (PCN) and antegrade pyelography. IV- Radio-isotope diuretic renogram using 99m Tc-MAG3. Results: 30 renal transplants were examined by MRI in the 1st 2 weeks after renal transplantation. At the end of 1st 2 weeks, MR examinations were carried out, as basal studies (including MRI, MRA and MRU) for 98 transplants. From this group, 64 transplants were subjected to other MR examinations. After the 1st 2 weeks, 53 transplants were subjected to MR examinations for the 1st time at variable post-transplant duration. Among the studied 181 renal transplants, MR examinations detected 3 cases with graft arteries thrombosis (1.6%), 10 with graft arteries stenosis (5.5%), 6 with segmental infarctions (3.3%), 3 cases with graft intrarenal arteries pseudo-aneurysms (1.6%) and 2 cases with arterio- venous fistulae (1.1%) after graft biopsies. Conclusion: MRI is highly recommended to evaluate intra-/extra-renal graft vascular lesions, urinary obstructive syndrome, compressive collections (urinoma, lymphocele), inflammatory and tumoral lesions of the renal graft.

An unusual presentation of neutropenic enterocolitis (typhlitis)

A 40-year-old man who had refractory, very severe, aplastic anaemia 6 months after an unsuccessful allogenic stem-cell transplant, presented with neutropenic (0·1 × 109/L) septic shock. Examination showed a tender papule on his thigh. Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli grew from the skin biopsy. Blood, urine, and stool cultures were all negative (no oganisms grew). CT showed many liver abscesses. The patient recovered after 6 weeks of ertapenem (1 g once a day) with teicoplanin (initially 200 mg once a day), remaining neutropenic throughout, but 12 days after fi nishing therapy he re-presented with pyrexia and additional skin lesions (fi gure A). Blood cultures grew the same ESBL-E coli as was isolated from the skin biopsy. CT showed pulmonary nodules suggestive of septic emboli with a healthy colon and biliary tract. PET showed uptake in the terminal ileum and wall-thickened caecum, con sistent with neutropenic enterocolitis (fi gure B). Neutropenic enterocolitis is a potentially life-threatening condition of the lower gastrointestinal tract (typically the caecum, in which it is termed typhlitis), where intestinal microbes invade the surrounding tissue of patients with neutropenia. Prevalence of this condition is rising because of liberal use of aggressive chemotherapy agents that damage the intestinal mucosa, and it is being increasingly recognised as a complication of stem-cell transplantation. Typhlitis usually produces a non-specifi c triad of fever, abdominal pain, and diarrhoea but can present as recrudescent fever or bacteraemia. Our patient’s presentation of skin (and probably liver and lung) septicemboli was unusual and emphasises the need for a high index of suspicion for this increasingly prevalent condition. Unexplained bacteraemia with enteric organisms in patients with neutropenia—especially if substantial and long lasting—should raise suspicion of typhlitis and trigger the necessary investigations, if another source for these organisms cannot be identifi ed. CT is regarded as the diagnostic imaging modality of choice for typhlitis, and usually shows bowel wall thickening of more than 4 mm. In our patient, CT did not show bowel wall thickening, but subsequent PET and ultrasonography both did. This diff erence shows that repeat imaging studies should be thought about for patients in whom the diagnosis of typhlitis is suspected. Management of typhlitis is predominantly conservative involving bowel rest, supportive measures, and correction of coagulopathies, thrombocytopenia, and neutropenia. Appropriate broad-spectrum antibiotics should be started promptly, but surgery is usually reserved for com plications such as perforation or if clinical deterioration continues despite conservative management. Our patient continued to receive ertapenem (1 g once a day) alongside teicoplanin (increased to 800 mg once a day) based on blood-culture sensitivities and allergy status. Unfortunately, he later died of complications arising from a second allogeneic transplant not connected with this episode of sepsis.

Clinical Presentation and Long-Term Outcome of Patients With Ectopic Acth Syndrome Due to Bronchial Carcinoid Tumors: A One-Center Experience

To describe the diagnostic features and long-term outcome of patients with bronchial carcinoid tumors with ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS), treated in our department. We studied 10 cases with EAS and histologically confirmed bronchial carcinoid tumors, diagnosed from 1992 until 2006. Diagnosis was based upon blood, urine, radiologic, and interventional tests. Disease status at the time of the last follow-up was the primary outcome measure. Clinical manifestations included Cushingoid features (100%), psychiatric symptoms (90%), hypertension (70%), diabetes/impaired glucose tolerance (40%), osteoporosis (10%), and hypokalemia (10%). The average time from the onset of symptoms until diagnosis was 14.2 ± 17.0 months. None of the patients exhibited a positive cortisol or ACTH response to corticotropin-releasing hormone (CRH) test, and none showed a positive gradient on bilateral inferior petrosal sinus sampling (BIPSS). All tumors were identified by computed tomography and by octreotide scintigraphy in 8 patients. All patients underwent surgical resection of the tumor, and 2 patients had adjuvant radiation therapy. The mean follow-up was 126.6 ± 63.3 months. At latest follow-up, 8 patients were in remission and 2 had recurrence of the EAS; both had a multifocal tumor. The 2 patients submitted to adjuvant radiation therapy were in remission at their latest follow-up, despite local invasion and lymph node metastases. CRH test and BIPSS are the most useful methods in diagnosing EAS. For localization, repeated imaging studies are necessary. Surgical treatment is effective in most cases. Adjunctive radiotherapy may be useful in patients with lymph node metastases. Patients with multifocal disease should be monitored for potential recurrence.

Severe Abdominal Pain in the Setting of an Intestinal Intussusception as a First Presentation of Celiac Disease

A 36-year-old woman with Hashimoto thyroiditis, anxiety, and a history of two pregnancies by C- section complicated by hyperemesis gravidarum requiring total parenteral nutrition (TPN), as well as previous idiopathic chronic urticarial, presented to the hospital with severe periumbilical pain. The pain started 4 days prior and was associated with watery non-bloody diarrhea, nausea, and non-bilious non-bloody vomiting. The pain was described as cramping and sharp pain that lasted minutes, over a background of continuous dull pain located in the periumbilical region. On examination, the patient was afebrile, with a normal respiratory and heart rate. Cardiovascular and pulmonary exam was unremarkable. Abdominal examination revealed periumbilical tenderness without guarding or rebound tenderness, and normal bowel sounds. Blood work revealed leukocytosis of 13.4 thousand/uL with a neutrophil predominance of 87%, mild anion gap of 17 with low bicarbonate level of 11.5 mmol/L. Computer tomography (CT) of the abdomen and pelvis with oral contrast showed evidence of ileoileal intussusception and extensive prominent abdominal lymphadenopathy. The patient underwent an exploratory laparoscopy that revealed no intussusception, but evidence of reactive lymphadenopathy that was sampled. Stool cultures, Clostridium difficile, ova and parasite cultures and Cryptosporidium antigen were negative. The patient's course was complicated by poor oral intake, nausea, vomiting and abdominal pain. She underwent multiple repeat imaging studies including magnetic resonance enterography and CT angiography, as well as esophagogastroduodenoscopy, enteroscopy and colonoscopy that revealed diffuse absence of villi and significant crypt hyperplasia consistent with Celiac sprue. Tissue transglutaminase IgA was also found to be elevated to 254.6 CU. She was started on a gluten free diet with persistence of symptoms. Subsequently she was treated with prednisone, and eventually required TPN with improvement of abdominal pain albeit not complete disappearance. Conclusion: Intestinal intussusception as a first presentation of celiac disease.

Splenic injury: a clinical study and management in a tertiary care hospital

Background: Splenic injury is one of the most commonly injured solid organs in blunt abdominal injury and it is often associated with significant mortality and morbidity. With the advancement in diagnosis and treatment, the management strategy has gradually changed to a non-invasive management. This study is aimed to study the Clinical presentation in a patient with splenic trauma, importance of FAST and CT scan in a patient with splenic trauma and to study the line of management in special reference to non-operative management. Methods: A retrospective study of 30 splenic injury patients who were admitted under the Department os Surgery, GMCH between June 2012 and May 2013 was done. Data regarding demographic details, mode of injury, investigation findings, management and outcome, hospital stay and follow up were recorded and analyzed. USG (FAST) and CT scan findings were used to grade the splenic injury. Results: 30 patients were included in the study. All patients with Grade I and Grade II injury were managed conservatively. In Grade III injury 5 patients were managed non-operatively and 7 patients operatively. In Grade IV injury 4 patients were managed non-operatively while 2 patients required operative intervention. In Grade V injury, 2 patients needed splenectomy while 2 were treated conservatively. Thus, there is a trend towards non operative management of splenic injury especially in the lower Grades. Conclusions: Non-operative management of splenic injury can be done without increased mortality and morbidity through proper monitoring, rest, blood transfusion and repeated imaging studies especially CT scan.

Early Complete Remission of Osteoid Osteoma with Conservative Medical Management

Osteoid osteoma is a benign bone tumor and causes persistent pain that is usually treated by surgery or ablation therapy. Conservative management with non-steroidal anti-inflammatory drugs (NSAIDs) is also used to avoid the morbidity associated with surgery or ablation therapy; however, it usually takes several years for the condition to resolve using conservative treatment. Our patient, a 10-year-old boy, presented with a 3-month history of a painful lesion in his leg. Plain radiography, bone scanning, computed tomography and magnetic resonance images showed the presence of a lesion with radiological features consistent with an osteoid osteoma of the cortex in the tibial diaphysis. The patient was treated with a usual dose of ibuprofen for 3 weeks. Within 3 weeks, his symptoms were almost completely resolved; he no longer needed NSAIDs and returned to normal life. Repeat imaging studies showed complete disappearance of the nidus within 2.5 years after the resolution of symptoms.

Positioning in Breast MR Imaging to Optimize Image Quality

Improper positioning of the breasts in a dedicated breast coil causes inhomogeneous fat saturation as well as other artifacts that decrease the sensitivity of breast magnetic resonance imaging. Improper positioning can create artifacts that can obscure a malignancy or cause it to be missed. Goals of proper positioning include imaging the maximum area of breast tissue, minimizing skin folds, and achieving homogeneous fat suppression and nondeformed breast parenchyma. Review of prior images gives the technologist an impression of what the positioning and imaging challenges may be in each patient before the patient enters the imaging unit. Checking the triplane localizer images and repositioning as necessary before any diagnostic or interventional imaging is key. Using a fat saturation pad, changing the arm position, or "rolling" the patient may be considered in difficult cases. Padding to support the patient in an oblique position, using angled sponges to increase breast compression thickness, and raising the grid to access posterior lesions may be helpful in targeting difficult-to-access lesions for biopsy. Using the presented positioning techniques and suggestions, in addition to strict attention to detail before imaging, will improve image quality, decrease imaging time and suboptimal images, and limit the need for repeat imaging studies.

Septic Cerebral Vein Thrombosis and Abnormal Leptomeningitis as a Complication From a Periodontitis in a Hispanic Male: Case Report and Literature Review

Sinus vein thrombosis is a rare form of stroke that results from thrombosis of the dural vein sinus. Despite the variety of diagnostic procedures and treatment, septic thrombosis of the cavernous sinus can cause significant morbidity and mortality if not diagnosed and treated as an emergency. The clinical presentation of proptosis that occurs suddenly accompanied by erythema of the eyelid and limitation of ocular movement should alert the clinician of the possibility of cavernous sinus thrombosis. A 38-year old Hispanic male presented with pounding headache, mainly in the occipital region that began 1 week prior to hospital admission. During the hospitalization the patient subsequently developed a progressive worsening of proptosis, lacrimation and neck pain. The MRI and venography of the brain showed a cerebral venous thrombosis (CVT) with a reactive diffuse leptomeningitis. The underlying cause was a chronic dental infection. The patient was treated with course of antibiotics and discharged. A few weeks later the repeated imaging studies showed a resolution of the CVT and leptomeningitis. Although rare, septic vein thrombosis (SVT) remains a potentially lethal complication of infections that involve the sinuses, face, ears and oral cavity. The early recognition and differentiation from other diseases are keys to reducing mortality rates and long-term sequelae. Advances in imaging, especially CT and MRI have contributed substantially to the rapid diagnosis of the condition. J Med Cases. 2013;4(9):598-601 doi: http://dx.doi.org/10.4021/jmc1370w

Mapping motion from 4D‐MRI to 3D‐CT for use in 4D dose calculations: A technical feasibility study

Target sites affected by organ motion require a time resolved (4D) dose calculation. Typical 4D dose calculations use 4D-CT as a basis. Unfortunately, 4D-CT images have the disadvantage of being a "snap-shot" of the motion during acquisition and of assuming regularity of breathing. In addition, 4D-CT acquisitions involve a substantial additional dose burden to the patient making many, repeated 4D-CT acquisitions undesirable. Here the authors test the feasibility of an alternative approach to generate patient specific 4D-CT data sets. In this approach motion information is extracted from 4D-MRI. Simulated 4D-CT data sets [which the authors call 4D-CT(MRI)] are created by warping extracted deformation fields to a static 3D-CT data set. The employment of 4D-MRI sequences for this has the advantage that no assumptions on breathing regularity are made, irregularities in breathing can be studied and, if necessary, many repeat imaging studies (and consequently simulated 4D-CT data sets) can be performed on patients and/or volunteers. The accuracy of 4D-CT(MRI)s has been validated by 4D proton dose calculations. Our 4D dose algorithm takes into account displacements as well as deformations on the originating 4D-CT/4D-CT(MRI) by calculating the dose of each pencil beam based on an individual time stamp of when that pencil beam is applied. According to corresponding displacement and density-variation-maps the position and the water equivalent range of the dose grid points is adjusted at each time instance. 4D dose distributions, using 4D-CT(MRI) data sets as input were compared to results based on a reference conventional 4D-CT data set capturing similar motion characteristics. Almost identical 4D dose distributions could be achieved, even though scanned proton beams are very sensitive to small differences in the patient geometry. In addition, 4D dose calculations have been performed on the same patient, but using 4D-CT(MRI) data sets based on variable breathing patterns to show the effect of possible irregular breathing on active scanned proton therapy. Using a 4D-CT(MRI), including motion irregularities, resulted in significantly different proton dose distributions. The authors have demonstrated that motion information from 4D-MRI can be used to generate realistic 4D-CT data sets on the basis of a single static 3D-CT data set. 4D-CT(MRI) presents a novel approach to test the robustness of treatment plans in the circumstance of patient motion.

Improved Cerebral Blood Flow Measurement with Multiexposure Speckle Imaging

Laser speckle contrast imaging (LSCI) is a powerful tool for in vivo imaging of blood flow dynamics. Based on the blurring of the random interference pattern (‘speckle') produced at the camera by laser light reflecting off a surface, LSCI has been rapidly adopted because of its high spatial and temporal resolution coupled with the relative simplicity and low cost of assembling a LSCI instrument. Wide-field maps of cerebral blood flow acquired via LSCI have made significant contributions to our understanding of cerebral hemodynamics in the healthy and ischemic brain in animal models.1, 2, 3, 4 More recently, LSCI has been applied in studies of human patients.5, 6 While the high-resolution maps of relative changes in blood flow acquired during LSCI have been well validated, flow estimates from LSCI are affected by a number of parameters unrelated to blood flow. As such, the exact quantitative relationship between speckle contrast and blood flow velocity has not been precisely defined.7, 8 The sensitivity of LSCI to nonflow parameters is particularly problematic in long-term studies where nonflow parameters are more likely to vary between imaging sessions. Recently, traditional single-exposure LSCI was extended with a multiexposure speckle imaging (MESI) protocol that improved quantitative accuracy in microfluidic flow simulations and in vivo imaging in rodents.9, 10 Using improved mathematical models and instrumentation to acquire speckle contrast images at multiple, defined exposures, MESI accurately estimates flow changes associated during acute ischemic stroke, contrary to the underestimates of flow changes associated with traditional single-exposure LSCI.10 However, the utility of MESI in long-term, repeated-imaging studies has not been validated. In the current issue, Kazmi et al11 perform MESI in mice implanted with chronic cranial imaging windows. Multiexposure speckle imaging data are compared with quantitative measurements of absolute blood flow acquired via high-frame rate red blood cell photography (RBC tracking). In healthy mice and mice with targeted ischemic strokes imaged over multiple days, MESI consistently quantified blood flow more accurately than single-exposure LSCI. Notably, by testing multiple exposure times, Kazmi et al demonstrated that no single exposure time was optimal in all animals and imaging sessions. By incorporating multiple exposure times and improved mathematical modeling, MESI better accounted for variations in imaging conditions and more reliably quantified the blood flow during chronic imaging. Improved quantitative accuracy is demonstrated by reduced deviation between flow measurements derived from MESI and RBC tracking (∼10%) relative to single-exposure LSCI and RBC tracking (∼24%). While the reliability of quantitative accuracy between animal comparisons remains to be confirmed, MESI significantly improves the quantitative accuracy of LSCI blood flow measurements in both acute and chronic imaging paradigms. This improved quantitative accuracy extends LSCI beyond qualitative descriptions of changes in flow, an important contribution to preclinical and clinical studies of stroke hemodynamics and flow restoration therapies.

Incidental White Matter Lesions in Children Presentıng With Headache

We aimed to describe the prevalence and significance of white matter lesions detected on magnetic resonance imaging (MRI) in children with headache. Children who were admitted with the complaint of headache and had neuroimaging between December 2007 and June 2012 were included in the study. The clinical and neuroimaging data of the patients were retrospectively evaluated. MRI results of the patients were documented in detail. The patients with non-specific white matter lesions were called for a control visit, and current status of headache and neurological findings were determined. A total of 941 patients were included in the study. Sixty-one percent of the patients received cranial neuroimaging. 8.2% had only cranial computed tomography (CT), 7.5% had cranial CT and cranial MRI, and 84.3% had only cranial MRI. 22.1% of the patients had abnormal cranial MRI findings. The rate of incidental non-specific white matter changes detected in our study group was 23/527 (4.4%). Among the 23 patients, 12 (52.2%) were male and 11 (47.8%) were female. Fourteen (60.9%) had migraine without aura, 8 (34.8%) had tension-type headache, and 1 (4.3%) had migraine with aura. Mean age of patients at the time of imaging was 12.1 ± 3.4 years (range 4.0-16.0 years). All patients with non-specific white matter changes on MRI showed normal psychomotor development, and there was no history of seizures or head trauma. The physical and neurological examinations of all patients were normal. The mean clinical follow-up period of the patients was 16.8 ± 17.3 months (range 6-80 months). No patients showed neurological deterioration during the follow up. The white matter lesions were supratentorial in all patients. The mean size of the lesions was 5.1 ± 4.5 mm (minimum, 2 mm; maximum, 24 mm). Repeated radiological evaluations were performed in 11 (47.8%) of the patients. No new white matter lesions were detected in control MRI during follow up. Non-specific incidental white matter changes may be seen in children with headache. For normal clinical follow up, in the absence of evident benefits from repeated imaging studies, we suggest that repeated imaging studies are not warranted in every patient and should be tailored according to clinical course.

1297 FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY FOR PREOPERATIVE STAGING AND POSTOPERATIVE FOLLOW-UP OF UROTHELIAL CARCINOMA

You have accessJournal of UrologyBladder Cancer: Detection & Screening1 Apr 20131297 FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY FOR PREOPERATIVE STAGING AND POSTOPERATIVE FOLLOW-UP OF UROTHELIAL CARCINOMA Anwar Alesawi, Andre Caron, Alain Bergeron, Helene Hovington, Vincent Fradet, Louis Lacombe, and Yves Fradet Anwar AlesawiAnwar Alesawi Quebec, Canada More articles by this author , Andre CaronAndre Caron Quebec, Canada More articles by this author , Alain BergeronAlain Bergeron Quebec, Canada More articles by this author , Helene HovingtonHelene Hovington Quebec, Canada More articles by this author , Vincent FradetVincent Fradet Quebec, Canada More articles by this author , Louis LacombeLouis Lacombe Quebec, Canada More articles by this author , and Yves FradetYves Fradet Quebec, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2651AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The treatment and prognosis of bladder cancer depends on lymph node involvement in addition to other factors, but the accuracy of conventional imaging modalities for the prediction of nodal involvement or even detection of recurrence in early stage is limited. This study retrospectively investigated the value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in the staging and follow up of urothelial carcinoma in comparison to contrast-enhanced computed tomography (CT). METHODS We reviewed 148 files of urothelial carcinoma patients. Of these, 134 had initial and 80 had follow-up PET/CT scans while 103 patients had initial and 82 had follow-up CT scans. Initial CT and PET/CT results were correlated with histopathology data (grade, stage and lymph node status). Follow-up CT and PET/CT results were confirmed by repeated imaging studies. RESULTS The sensitivity for detecting lymph node metastasis before surgery was 43.39% vs 43.58% while the specificity was 100% vs 95.23% for PET/CT scan vs CT scan, respectively. PET/CT scan had higher specificity in detecting recurrence (97.87% vs 90.19%) with higher positive predictive value (96.97% vs 85.7%). There was a significant association between recurrence discovered by PET/CT scan and the nodal status as 86.7% of patients who developed recurrence had positive lymph node whereas 13.3% had negative lymph node at surgery (p<0.0001, chi square). In addition, stage status at surgery was significantly associated with PET/CT scan discovered recurrence as 86.7% of patients who developed recurrence were ≥pT3 while 13.3% were ≤pT2 (p<0.005, chi square). CONCLUSIONS PET/CT scan is not inferior to CT scan in detecting positive lymph nodes before surgery of urothelial cancers while it is superior to CT scan in detecting recurrence after surgery. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e530 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anwar Alesawi Quebec, Canada More articles by this author Andre Caron Quebec, Canada More articles by this author Alain Bergeron Quebec, Canada More articles by this author Helene Hovington Quebec, Canada More articles by this author Vincent Fradet Quebec, Canada More articles by this author Louis Lacombe Quebec, Canada More articles by this author Yves Fradet Quebec, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pediatric Neck Masses

Pediatric Neck Masses

Patterns of Anterior Abdominal Stab Wounds and Their Management at Princess Basma Teaching Hospital, North of Jordan

With the progressive use of new diagnostic techniques, the management of penetrating abdominal stab wounds is changing. Most studies have been conducted in well-equipped trauma centers in developed countries, and there is a paucity of reports from general teaching hospitals with limited resources. We reviewed the assessment of anterior abdominal stab wounds in patients presenting to our hospital hoping to establish an evidence-based algorithm for managing such patients in busy general hospitals. The medical records of all 393 patients treated at our hospital for anterior abdominal stab wounds over a 7-year period were reviewed. Information regarding age, gender, site of the stab wound, management, and complications were analyzed. Twenty-six patients with hemodynamic instability at presentation underwent urgent laparotomy (LAP); 24 (92.3 %) of those procedures were therapeutic. Local wound exploration (LWE) proved that 114 (31 %) of all hemodynamically stable patients had no abdominal fascia penetration and consequently could be discharged home from the emergency department (ED). A total of 253 patients were found to have fascial penetration, and all were admitted for repeat clinical assessments (RCA) and imaging studies. A total of 121 (48 %) of the patients underwent abdominal exploration with 102 (84 %) therapeutic LAP procedures. Hemodynamic instability and evisceration should continue to prompt urgent LAP. For stable patients, a sequence of LWE followed by focused abdominal sonography for trauma and computed tomography scanning for unclear cases primed by RCA was found to be efficient in limiting hospital admissions and reducing the rate of non-therapeutic LAP.