T1 Low Intensity Research Articles

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Cervical Spine Trauma: 18. The relationship between subacute MRI and walking ability, urinary function at the chronic stage in patients with cervical spinal cord injury

BACKGROUND CONTEXT Some papers reported about the relationship between the MRI features and the clinical outcomes in patients with cervical spinal cord injury (CSCI) at the acute stage following trauma. However, to the best of our knowledge, there is no paper reporting about the relationship between MRI features and activities of daily living of patients at chronic stage. PURPOSE The purpose of this study was to investigate the relationship between the subacute MRI features and the clinical outcomes at chronic stages, especially walking ability and urinary function in patients with cervical spinal cord injury (CSCI). STUDY DESIGN/SETTING A retrospective imaging and clinical study. PATIENT SAMPLE Eighty-six patients with CSCI who were admitted to our hospital within 7 days after injury were included in this study. The diagnosis was 66 patients for CSCI without major bone injury and 20 patients for CSCI with fracture or dislocation. Seventy-two males and 14 females, and the average age at the time of injury were 62.2 years (16-88 years). Paralysis at the time of admission was graded as A in 25, B in 7, C in 32, and D in 22 patients on the basis of the ASIA impairment scale. OUTCOME MEASURES Patients were followed up for average 7.5 months (range, 4-14 months). MRI was performed for all patients at within 24 hours after admission (acute stage) and 1 month following injury (subacute stage). Using the MRI sagittal images, we measured the vertical and transverse diameter of intramedullary intensity changed area with T1 and T2-weighted images at the injured segment. Neurological evaluation was performed using ASIA motor score, the modified Frankel grade and urination status at the time of admission, 1 month, and 6 months following injury. METHODS We evaluated the relationship between the size of intensity-changed area in MR images (T1 low and T2 high intensity areas) and ASIA motor score, walking ability and urinary function. This study was approved by our Institutional Review Board, and written informed consent was obtained from all the patients. RESULTS In the MR images at subacute stage, T1 low-intensity area, which was not seen at acute stage, appeared in 73 (84.8%) in 86 patients. There was a significant relationship between the transverse diameter of T1 low-intensity area in MR image at subacute stage and walking ability, urination function at 6 months following injury. ASIA motor score at admission also showed a significant correlation with walking ability, urination function at 6 months following injury. Receiver operator characteristic (ROC) curve analysis demonstrated that the optimal transverse diameter of T1 low-intensity area cut-off value for patients who were able to walk with or without a cane at 6 months following injury was 46%. The optimal transverse diameter of T1 low-intensity area cut-off value for patients who were able to self-urinate at 6 months following injury was 30%. ROC curve analysis demonstrated that the optimal ASIA motor score at admission cut-off value for patients who were able to walk with or without a cane at 6 months following injury was 46. The optimal ASIA motor score at admission cut-off value for patients who were able to self-urinate at 6 months following injury was 50. Twenty of the 21 patients (95.2%) with no or less than 1/3 of the cord transverse diameter of T1 low-intensity area, and with admission ASIA motor score 50 or more recovered able to walk with or without a cane, and able to self-urinate at 6 months following injury. CONCLUSIONS The ASIA motor score at admission and subacute T1 low-intensity area were significantly correlated with the walking ability and urination function of the patient at 6 months following injury. With this data, we can infer the activities of daily living of patients at chronic stage and educate patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Complete mimicry: a case of alveolar rhabdomyosarcoma masquerading as acute leukemia

BackgroundA small number of rhabdomyosarcoma (RMS) cases involve the bone marrow. A leukemic presentation of RMS has been reported in a few case series, although almost all cases of leukemic RMS are not completely mimicking leukemia. We encountered a case with RMS cell infiltration of the bone marrow that resembled floating hematological cells.Case presentationWe encountered a rare case of a 15-year-old boy with a 2-week history of left femoral pain. Upon admission, he was afebrile with no other symptoms. No apparent cause of femoral pain was detected on an initial examination. Laboratory findings revealed normal white blood cell (WBC) count and hemoglobin concentration, with a platelet count of 10.3 × 104/μL. WBCs included 2.0% metamyelocytes, 4.5% myelocytes, and 0.5% blasts. Lactate dehydrogenase concentration was 1299 U/L, creatine kinase was 437 U/L, and C-reactive protein was 1.25 mg/dL. Bone marrow aspiration demonstrated hypercellular marrow (nucleated cell count 1.84 × 104/μL) and 89.0% of blast-like cells of all nucleated cells. The proliferating cells were negative for myeloperoxidase and esterase, and strongly positive for CD56. Positron emission tomography exhibited extensive accumulation of 18F–fludeoxyglucose with a SUVmax of 7.09. Magnetic resonance imaging revealed T1-low intensity, gadolinium-enhanced, diffuse, and irregular lesions on his pelvis and bilateral femurs. These laboratory and imaging findings suggested hematological malignancy with diffuse bone involvement, suggestive of acute leukemia. However, the pathological diagnosis of bone marrow and basal penile muscle biopsy was alveolar RMS. Karyotype analysis of bone marrow cells revealed the characteristic translocation of t(2;13)(q35;q14). The final diagnosis was alveolar RMS with massive involvement of the bone marrow and the primary site in the perineal muscles. The tumor cells both of the primary site and bone marrow were positive for myogenin.ConclusionsA literature review found a misdiagnosed case of completely mimicking leukemic RMS as natural-killer (NK)-cell leukemia. Such a misdiagnosis can have critical consequences. We experienced a rare case of alveolar RMS with symmetrical diffuse bone marrow involvement completely masquerading as acute leukemia. The results of a surface marker study showing that the tumor cells had a near NK-cell phenotype were misleading.

A Case of Infrapatellar Fat Pad Ganglion of the Knee.

Introduction:A ganglion cyst can induce symptoms around the knee and should be considered as an intra-articular mass in differential diagnosis.Case Presentation:A 22-year-old female presented with a persistent medial knee joint pain in her left knee for 2 years. There was soft tissue swelling on the anteromedial aspect of the infrapatellar region on her left knee. Lachman and McMurray tests were negative. MRI showed a multilobular cyst in the infrapatellar fat pad with T1 low intensity and T2 STIR high intensity. The cyst was not attached to either meniscus. ACL and PCL looked normal.During surgery, the cyst was found to arise from the intra-patellar fat pad and was not attached to the menisci or synovium. The cyst was completely resected.Histological findings showed a multilobular cyst with a glassy fibrous tissue wall and clear jelly-like consistency, confirming the diagnosis of a ganglion. The patient recovered asymptomatically and has been without recurrence 7 years postoperatively.Conclusion:Differential diagnoses of an infrapatellar swelling are a meniscal cyst, synovial cyst, or ganglion. Most cases of cysts around the knee generate from fluid collection through meniscal tears. A ganglion cyst is a synovium-lined structure and is common around the wrist joint, but rare in the knee joint. A ganglion cyst in the knee joint often arises from ACL or PCL, but rarely arises from the infrapatellar fat pad. A ganglion cyst is one of the differential diagnoses of parameniscal cysts around the knee. We recommended an open resection with arthroscopic examination.

Subacute T1-low intensity area reflects neurological prognosis for patients with cervical spinal cord injury without major bone injury.

A retrospective imaging and clinical study. To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury. A total of 72 patients with CSCI without major bone injury were treated conservatively in our hospital. MRI was performed for all patients at admission and 1 month following injury. We measured the antero-posterior and cranio-caudal diameter of intramedullary intensity changed area with T1-weighted images at the injured segment. Neurological evaluations were performed using the American Spinal Injury Association (ASIA) motor score and the modified Frankel grade at the time of admission and discharge. There was a significant relationship between the antero-posterior diameter ratio of the T1-weighted low-intensity area on MRI at the subacute stage and the ASIA motor score. The optimal threshold of the T1-weighted low-intensity diameter ratio for predicting the patient's ability to walk with or without assistance at discharge was determined to be 46%. Moreover, 96.8% of the patients with <50% T1-weighted low-intensity area recovered to walk with or without a cane at discharge. The T1-low intensity area may be an important predictive factor for the neurological recovery of CSCI without major bone injury.

Primary cauda equina lymphoma: case report and literature review.

The central nervous system, in particular the spinal cord, is a rare site for primary lymphoma occurrence, with very few published cases. We report an extremely rare primary lymphoma in the cauda equina in a single case with literature review. An immunocompetent 59-year-old male, who complained of progressive low back and bilateral leg pain for 7 months, was studied. Magnetic resonance imaging (MRI) revealed an intradural space-occupying lesion from T12 to S1, poorly demarcated to the normal cauda equina. The intradural lesion showed T1 low intensity, T2 low isointensity, and marked homogeneous enhancement with gadolinium-diethylenetriaminepentaacetic acid on MRI. We performed spinal tap to obtain additional information about the intradural lesion. Large-sized atypical lymphoid cells were found during pathological examination. Fluorodeoxyglucose accumulation was found only in the lumbar area, which corresponded with the MRI findings, and the primary lymphoma site was defined as the cauda equina area. For further detailed pathological diagnosis, we performed surgical biopsy of the cauda equina. Morphological and immunohistochemical assessment made a diagnosis of diffuse large B-cell lymphoma of the cauda equina. The patient received radiotherapy to the lumbosacral area (50 Gy) and methotrexate (MTX) therapy after surgery. The patient was able to walk without help after the therapies. Follow-up MRI performed 1 year after biopsy showed remission of the lesion. MRI and spinal tap were effective tools for the early definitive diagnosis of cauda equina lymphoma. Combined treatment with radiotherapy and MTX should be performed as early as possible.

Intramedullary lipoma and epidermoid—rare coincidence in elderly

Objectives: The incidence of intramedullary lipoma or epidermoid is less than 1% of all spinal tumors, particularly in adulthood. A variety of concurrent spinal anomalies can be found: from occult spinal dysraphism, dermal sinus tracts, hypertrichosis, spina bifida, to dural bands, tethered spinal cord with thick filum terminale to lipoma, epidermoid, diastematomyelia and lipomeningomyelocele. The typical manifestation in the elderly is low extremity pain, weakness, paresthesia, paraparesis, hyperreflexia and sphincter disorders. The onset of symptoms occurs often after sudden stretching or after low-intensity trauma, but relatively asymptomatic development can be found over a longtime period. Method: The authors present their experiences with three patients over a 20-year period. Intradural exploration was performed in two cases; microsurgical technique was used and all associated anomalies were operated on during the same operation. Results: MR was the imaging tool of choice. Diagnosis of lipoma is based on the T1 and T2 image with high-signal intensity, contrary to epidermoid (T1 low intensity, T2 very high-signal intensity and proton density differing from CSF, image possibly inhomogenous, sharply marginated or lobulated). Enhancement effect is not present in both lesions. The findings of the MRI were difficult to interpret. Microsurgical treatment differs in this. For epidermoid, we recommend intracapsular decompression and radical removal of the capsule, the only growing part of the tumor, with close adherence to the neurovascular structures, because the remnant can produce recurrency of the lesion. In spite of this fact, lipoma is the nongrowing part of this common lesion, and there is no cleavage space between the medulla and tumor. Therefore, only partial removal with a safe strip of tissue left is recommended. The treatment of concurrent anomalies is mandatory. Conclusion: The conventional explanation for clinical symptoms is tethering of the anchored spinal cord, stretching and low-intensity injury or, more often, involution changes. The authors also suggest that progressively slow linear growth with compression of the neurovascular structures can cause late clinical manifestations in the elderly. On the basis of their limited experiences, the authors do not recommend prophylactic surgery in asymptomatic or stabilized patients.

Ｔｕｍｏｒａｌ ｃａｌｃｉｎｏｓｉｓに合併した脆弱性骨折の１例

We report a case of insufficiency fracture in the left hip joint, in which giant tumoral calcinosis occurred during hemodialysis.The patient was a 36-year-old male on chronic maintanance hemodialysis for 11 years. He experienced left thigh pain upon awaking. Roentgenograms showed a calcified mass in the bilateral hip joint and right shoulder joint. Laboratory tests including intact parathyroid hormone (i-PTH) level were normal, except for increases in serum calcium and phosphorus.MRI showed that T1 low intensity and T2 high intensity areas around the hip joint subcutaneous and intramuscle.We performed osteosynthesis with ender nailing, and biopsy of a part of the fracture, and calcinosis in the left hip joint. Microscopic examination revealed calcareous deposits limited by bands of fibrous connective tissue and giant cell. Eel calcitomin puls therapy was given after every hemodialysis. Three months later, after right shoulder calcinosis was decreased on X-ray.