Typical MRI Findings Research Articles

MRI of Small Hepatocellular Carcinoma: Typical Features Are Less Frequent Below a Size Cutoff of 1.5 cm.

The purposes of this study were to analyze MRI features of small hepatocellular carcinomas (HCCs) on the basis of size and to evaluate the difference in frequency of typical radiologic hallmarks of HCC (arterial enhancement and washout) according to the tumor size. Enrolled were 86 patients with 110 HCCs 3 cm or smaller who underwent surgical resection or transplantation. Two radiologists reviewed gadoxetic acid-enhanced MRI features for signal intensity of T2-weighted and T1-weighted imaging, diffusion restriction, presence of arterial enhancement, washout on portal and transitional phases, and signal intensity on the hepatobiliary phase. ROC curve analysis was performed to determine the optimal HCC cutoff size for radiologic hallmarks of HCC. Tumors were divided into two groups by cutoff size, and the frequencies of MRI features were assessed. On ROC analysis, the optimal cutoff for radiologic hallmarks of HCC was 1.5 cm in independent and consensus reviews by two radiologists. HCCs smaller than 1.5 cm showed typical finding of HCC less frequently than HCCs 1.5 cm or larger in diameter. In subgroup analyses, HCCs with diameters between 1 and 1.5 cm showed similar MRI findings to HCCs with diameters 1 cm or less but significantly different findings compared with HCCs with diameters from 1.5 to 2 cm and 2-3 cm. HCCs smaller than 1.5 cm in size less frequently showed MRI findings seen typically in larger HCCs. Therefore, small HCCs are harder to detect with certainty not only because of small size but also because of the lower frequency of typical MRI findings.

Sporadic Creutzfeldt Jakob Disease: A Patient with Dementia and Involuntary Movement Myoclonus

Creutzfeldt Jakob Disease (CJD) is an incurable, invariably fatal, rapidly progressive neurodegenerative disease caused by an abnormal isoform of a cellular glycoprotein known as the prion protein. CJD occurs worldwide, estimated annual incidence is about one case per million populations per year. Sporadic (sCJD) is a human prion disease; infection with this disease usually leads to death within one year of onset of illness. The characteristic clinical and diagnostic features of rapidly progressive dementia, myoclonus, visual or cerebellar signs, pyramidal and extrapyramidal signs, akinetic mutism and positive result on the presence of 14-3-3 protein in CSF assay, typical EEG features and MRI findings of brain are highly suggestive of diagnosis. Biopsy of brain for histopathological examination is more specific and confirmatory for diagnosis. This article reports a 65 years old lady of sCJD who was diagnosed by characteristic findings of MRI of brain, Electro-encephalography (EEG) and cerebrospinal fluid (CSF) assay at National University Hospital (NUH) Singapore and now admitted at United Hospital Limited (UHL) Dhaka for palliative and supportive management
 Journal of Armed Forces Medical College Bangladesh Vol.12(2) 2016: 141-144

Autoimmune polyendocrinopathy and hypophysitis after Puumala hantavirus infection.

SummaryPuumala hantavirus (PUUV) infection causes nephropathia epidemica (NE), a relatively mild form of haemorrhagic fever with renal syndrome (HFRS). Hypophyseal haemorrhage and hypopituitarism have been described in case reports on patients with acute NE. Chronic hypopituitarism diagnosed months or years after the acute illness has also been reported, without any signs of a haemorrhagic aetiology. The mechanisms leading to the late-onset hormonal defects remain unknown. Here, we present a case of NE-associated autoimmune polyendocrinopathy and hypopituitarism presumably due to autoimmune hypophysitis. Thyroid peroxidase antibody seroconversion occurred between 6 and 12 months, and ovarian as well as glutamate decarboxylase antibodies were found 18 months after acute NE. Brain MRI revealed an atrophic adenohypophysis with a heterogeneous, low signal intensity compatible with a sequela of hypophysitis. The patient developed central (or mixed central and peripheral) hypothyroidism, hypogonadism and diabetes insipidus, all requiring hormonal replacement therapy. This case report suggests that late-onset hormonal defects after PUUV infection may develop by an autoimmune mechanism. This hypothesis needs to be confirmed by prospective studies with sufficient numbers of patients.Learning points:Pituitary haemorrhage resulting in hypopituitarism has been reported during acute HFRS caused by PUUV and other hantaviruses.Central and peripheral hormone deficiencies developing months or years after HFRS have also been found, with an incidence higher than that in the general population. The pathogenesis of these late-onset hormonal defects remains unknown.This case report suggests that the late-onset hypopituitarism and peripheral endocrine defects after HFRS could evolve via autoimmune mechanisms.The sensitivity of current anti-pituitary antibody (APA) tests is low. A characteristic clinical course, together with typical brain MRI and endocrine findings may be sufficient for a non-invasive diagnosis of autoimmune hypophysitis, despite negative APAs.

Clinical outcome following DIAM implantation for symptomatic lumbar internal disk disruption: a 3-year retrospective analysis.

Background/objectiveInternal disk disruption (IDD), an early event of lumbar disk degeneration, is the most common cause of low back pain. Since increased intradiskal pressure (IDP) is associated with symptoms and progression of disk degeneration, unloading a painful disk with an interspinous process device (IPD) is a rational treatment option. The goal of this study was to evaluate the effectiveness of dynamic stabilization with an IPD in the treatment of symptomatic IDD of the lumbar spine.Patients and methodsPatients with symptomatic IDD were treated with implantation of an IPD, the device for intervertebral assisted motion (DIAM). Diagnosis of IDD was based on typical MRI finding of posterior annular high-intensity zone and positive provocative test on discography. IDP was analyzed intraoperatively. Axial back and leg pain was evaluated with visual analog scale, functional status with Oswestry Disability Index, and final clinical outcomes with Odom criteria. Data from 34 patients followed up for at least 3 years were collected.ResultsDIAM implantation significantly reduced IDP (n=11, P<0.0001). All 34 patients reported symptom relief. Thirty-one patients (91%) remained symptom free until the last followups. Three patients (9%) experienced recurrence of pain, of which the causes were unrelated to the IDD or surgery. Disk status at the DIAM-implanted segments remained stable. Segmental flexion/extension mobility was preserved in 27 of 30 patients with preoperative mobility. No proximal or distal adjacent segment degeneration was observed. The final clinical outcomes were excellent/good in 31 and fair/poor in three patients.ConclusionFor patients with symptomatic IDD, dynamic stabilization with DIAM provides pain relief and functional improvement. The implantation maintains disk status and prevents progression of disk degeneration, without compromising segmental flexion/extension mobility or causing adjacent segment degeneration.

Using 3.0 T MR to dynamically observe ablated lung tumors after percutaneous cryotherapy therapy

Objective: To initially explore MRI features and its changing trends including of lung tumors after Argon-Helium cryoablation therapy, and enhance the recognition of MR findings of lung tumors postcryoablation. Methods: Twenty-three cases of patients with twenty six nodules of pulmonary malignance who received Argon-Helium cryoablation therapy in Henan Cancer Hospital from July 2014 to January 2016 were enrolled.All patients underwent unenhanced and dynamic contrast-enhanced MRI scans at pre-and 1-day, 1-week, 1-, 3-, 6-, 12-month postcryoablation. Two radiologists independently reviewed MRI images, signal intensity in the ablated zone on T1WI and T2WI were assessed by a 5-point scale.The changing trends of size and signal intensity with time were showed by time-maximum diameter and time-score curve.Time-signal intensity curves based on dynamic enhanced sequence were also performed. Results: Typical MRI findings includes: heterogeneous signal intensity on both T1WI and T2WI at 1-day postcryoablation(26/26, 100%). Hyper-intense on T1WI(22/26, 84.6%) and T2WI(17/26, 65.4%) with a hypo-intense rim at 1-week postcryoablation.Decreasing signal intensity on T1WI(17/26, 65.4%) and increasing signal intensity on T2WI(22/26, 84.6%) at 1-month.Signal intensity declined to the level of muscle on both T1WI(18/26, 69.2%) and T2WI(19/26, 73.1%) at 3-month, nineteen ablated zone turned into patchy shape(19/26, 73.1%). The maximum diameter was largest at 1-day and gradually shrunk with time. The mean score value toped at 1-week and gradually decreased. A straight line type without definite enhancement was found from 1-day to 1-month postcryoablation, an inflow curve with a mild delayed enhancement was seen from 3- to 12- month. Totally 4 recurrence (4/26, 15.4%) all occurred at 3-month and were lack of a complete hypo-intense rim at 1-week postcryoablation. Conclusion: MRI findings of lung tumors postcryoablation are characteristic, a complete hypo-intense rim at 1-week is helpful to determine further recurrence, 1-week to 3-month is an important period to observe significant change of the ablation zone, MRI is valuable in identifying the ablation zone and can reflect its evolution with time.

The effect of transcranial direct current stimulation on seizure frequency of patients with mesial temporal lobe epilepsy with hippocampal sclerosis

ObjectivesTranscranial direct current stimulation (tDCS) is a non-invasive and safe method tried in drug-resistant epilepsies, in recent years. Our aim was to evaluate the effect of tDCS in patients diagnosed with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) which is a well-known drug-resistant focal epilepsy syndrome. Patients and methodsTwelve MTLE-HS patients diagnosed with their typical clinical, EEG and MRI findings fulfilling the criteria for drug-resistance as suggested by the ILAE commission were included after Ethics Committee approval and their signed consent. All patients received modulated cathodal stimulation; 2mA for 30min on 3 consecutive days. All patients also received sham stimulation with the same electrode positions; designed as 60s stimulation gradually decreasing in 15s with placement of the electrodes for 30min over the stimulation side. They were followed up by standard seizure diaries and their medical treatment was not changed during the study period. Their seizure frequencies both before and after cathodal tDCS and sham stimulation were compared statistically. Adverse effects were also questioned. ResultsMean age of our study group was 35.42±6.96 (6 males; median: 35.50). The mean seizure frequency was 10.58±9.91 (median=8; min-max=2-30) at the baseline and significantly decreased to 1.67±2.50 (median=0.5; min-max=0-8) after cathodal tDCS application (p=0.003). Ten patients (83.33%) had more than 50% decrease in their seizure frequencies after cathodal tDCS. Two patients (16.67%) also showed positive sham effect. Six patients (50%) were seizure-free in the post-cathodal tDCS period of one month. No adverse effect has been reported except tingling sensation during cathodal stimulation. ConclusionOur small series suggested that cathodal tDCS may be used as an additional treatment option in MTLE-HS. It may be tried in TLE-HS patients waiting for or rejecting epilepsy surgery or even with ineffective surgery results. More studies are needed with large series of patients to investigate the effects of tDCS in drug resistant epilepsies.

Management of Neurologic Manifestations in Patients with Liver Disease

Liver disease, both in its acute and chronic forms, can be associated with a wide spectrum of neurologic manifestations, both central and peripheral, ranging in severity from subclinical changes to neurocritical conditions. Neurologists are frequently consulted to participate in their management. In this review, we present an overview of management strategies for patients with hepatic disease whose clinical course is complicated by neurologic manifestations. Type A hepatic encephalopathy (HE), which occurs in acute liver failure, is a neurologic emergency, and multiple measures should be taken to prevent and treat cerebral edema. In Type C HE, which occurs in chronic liver disease, management should be aimed at correcting precipitant factors and hyperammonemia. There is an increasing spectrum of drug treatments available to minimize ammonia toxicity. Acquired hepatocerebral degeneration is a rare complication of the chronic form of HE, with typical clinical and brain MRI findings, whose most effective treatment is liver transplantation. Epilepsy is frequent and of multifactorial cause in patients with hepatic disease, and careful considerations should be made regarding choice of the appropriate anti-epileptic drugs. Several mechanisms increase the risk of stroke in hepatic disease, but many of the drugs used to treat and prevent stroke are contraindicated in severe hepatic failure. Hepatitis C infection increases the risk of ischemic stroke. Hemorrhagic stroke is more frequent in patients with liver disease of alcoholic etiology. Viral hepatitis is associated with a wide range of immune-mediated complications, mostly in the peripheral nervous system, which respond to different types of immunomodulatory treatment. Several drugs used to treat hepatic disease, such as the classical and the new direct-acting antivirals, may have neurologic complications which in some cases preclude its continued use.

MRI features and differential diagnosis of real and pseudo-tears of lateral meniscus at the insertion site of meniscofemoral ligament

Objective To analyze MRI features of real tears and pseudotears of posterior horn of the lateral meniscus (PHLM) at the insertion site of meniscofemoral ligament(MFL), and to discuss main points of differential diagnosis. Methods MR images of 32 patients with PHLM tears and 30 patients with anterior cruciate ligament tears but without PHLM tears confirmed by arthroscopy were analyzed retrospectively. Another 20 asymptomatic volunteers as controls underwent MR examination and analyzed. The number of consecutive slices displaying longitudinal increased signal in sagittal images and the length in axial images were evaluated. The one-way analysis of variance, χ2 test and ROC curve were used to analyze diagnostic value of different MRI findings. Results Longitudinal line with abnormal increased signal (pseudotear) was found in 82.0% (41/50) normal insertion site of MFLs. The typical MRI finding of real tears was peripheral longitudinal linear high signal in PHLM which reached the margin of articular surface. In sagittal images, longitudinal linear high signal was shown in (5.8±1.2) slices in knees of real tears, which was more than (2.6±1.1) slices and (2.7±1.4) slices in pseudo-tear groups (F=60.9, P<0.01). The area under ROC curve was 0.96 for differentiating real tear from pseudo-tear using the number of consecutive slices displaying longitudinal increased signal in sagittal images. With a threshold of five or more consecutive images with abnormal longitudinal increased signal as the positive standard of continuous-line sign, the overall sensitivity, specificity and accuracy for diagnosing real tear were 90.6% (29/32), 90.2% (37/41) and 90.4% (66/73), respectively. The axial images showed that the length of increased signal line in the outer of PHLM was (16.4±4.9) mm in patients with real tears, which was longer than pseudo-tear groups with length of (8.1±3.2) mm and (6.0±3.1) mm (F=17.0, P<0.01). The area under ROC curve was 0.92 for differentiating real tear from pseudo-tear using the length in axial images. The zip sign was defined when its length was not less than 10 mm. The sensitivity, specificity and accuracy of the zip sign was 84.4% (27/32), 90.2% (37/41) and 87.7% (64/73) respectively. In coronal images, high signal of MFL attachment insertion was shown in 71.9% (23/32), 60.0% (15/25) and 10/16 cases, there was no significant difference (χ2=0.98, P=0.61). Conclusion The continuous-line sign and zip sign are characteristic findings of PHLM tears at the insertion site of MFL attachment, which are valuable for differential diagnosis with pseudotears at the insertion site of MFL. Key words: Menisci, tibial; Ligaments; Wounds and injuries; Magnetic resonance imaging

Lymphangioma an unusual adult scrotal lump: case report and review

Cystic lymphangiomas are congenital lymphatic malformations that most commonly develop in the neck, axilla, mediastinum and retroperitoneum. They occur usually in children but occasionally in adults. The scrotum is a very rare site for this tumor and only few cases have been reported in the literature. We report the case of a scrotal lymphangioma in a 24-year-old male patient who developed painless scrotal swelling. Typical sonography and MRI findings are shown. Surgical excision and histopathology confirmed the diagnosis.

Subchondral Insufficiency Fracture of the Femoral Head Caused by Excessive Lateralization of the Acetabular Rim

We present a case of a 53-year-old woman with subchondral insufficiency fracture (SIF) of the femoral head without history of severe osteoporosis or overexertion. Plain radiographs showed acetabular overcoverage with excessive lateralization of the acetabular rim. A diagnosis of SIF was made by typical MRI findings of SIF. The lesion occurred at the antipodes of the extended rim. Increased mechanical stress over the femoral head due to impingement against the excess bone was suspected as a cause of SIF. The distinct femoral head deformity is consistent with this hypothesis. This is the first report of SIF associated with acetabular overcoverage.

Liponeurocytoma of Cerebellum: rare entity, case based study

Abstract Cerebellar liponeurocytoma (LNC) is a very rare neuroepithelial tumor. About thirty eight cases have been reported, in literature till date, mostly in the form of isolated case reports due to rarity of the occurrence. Authors report interesting case in 27-year old male presented with headache and cerebellar signs. MRI imaging revealed posterior fossa mass. He underwent sub occipital ctraniectomy with gross total resection of lesion. Histopathological report of specimen was consistent with liponeurocytoma with range of MIb index less than three. He is under regular follow-up. However he was not advised any adjuvant therapy. Diagnosis of LNC requires high index of suspicion and neuroimaging with typical MRI findings may be help to confirm the diagnosis. The tumor needs to be differentiated from medulloblastoma, which is far more common and aggressive and requires post-operative chemo-radiation and carries poor prognosis Management and pertinent literature will be reviewed

Non-schwannomatosis lesions of the internal acoustic meatus-a diagnostic challenge and management: a series report of nine cases.

Vestibular schwannomas (VS) are the most common lesions of cerebellopontine angle (CPA) corresponding to 76-91% of the cases. Usually, these lesions present typical CT and MRI findings. Non-schwannomatous tumors restricted to the internal auditory meatus (IAM) are rare and their preoperative radiological diagnosis may be difficult. This article describes nine surgically treated intrameatal non-schwannomatous lesions (NSL) and reviews the literature. In the last 16years, a total of 471 patients with diagnosis of VS were operated on in our department. Preoperatively, 42 patients had diagnosis of intrameatal schwannomas, but surgery revealed in nine cases NSL (3 meningiomas, 3 arachnoiditis/neuritis, 1 cavernoma, 1 vascular loop, and 1 arachnoid cyst). Most frequent symptoms presented by patients with NSL were hearing loss 89% (8/9) of patients, tinnitus 78% (7/9), and vertigo 33% (3/9). Almost all lesions (8/9) presented MRI findings of isointense signal in T1W with contrast enhancement. The only exception was the arachnoid cyst with intracystic bleeding, which was hyperintense in T1W that is not enhanced with contrast. This series shows an occurrence of 21.4% of non-schwannomatous tumors in 42 cases of lesions restricted to the IAM. Whenever a solely intrameatal enhanced tumor is detected, it is necessary to think about other diagnostic possibilities rather than VS. Therapeutic management may be changed, specially if radiosurgical treatment is considered.

OP17 – 2537: Epilepsy, clinical presentation and MRI features in patients with COL4A1 mutations

Objective COL4A1 mutations disrupt the integrity of basement membranes and therefore predispose to a broad spectrum of disorders affecting multiple organ systems, but most notably causing cerebral small vessel disease. There is little data on epilepsy in these patients. The aim of our study was to describe characteristics of epilepsy in patients with COL4A1-mutations including therapeutical aspects, to establish diagnostic criteria on the basis of typical MRI findings and to evaluate co-morbidities. Patients and methods Data was collected retrospectively by attending physicians via standardized questionnaires. MRI images were reviewed by one experienced pediatric radiologist in our centre (PW). Results All 6 patients had history of pre- or perinatal stroke or cerebral hemorrhage and later showed impairment of cognitive functions and motor development. Epilepsy in all patients manifested within the first year of life (3–10 months, mean: 6 months). Multiple antiepileptic drugs were administered (4–11; mean: 6.3); among those, valproic acid (4/6) and vigabatrin (4/6) proved effective whereas oxcarbazepine had aggravating effects in 2/6 patients. All patients showed co-morbidities such as ophthalmological disorders (6/6), microcephaly (6/6), and elevation of plasma creatine kinase levels (4/6). We identified generalized leukomalacia in one or both cerebral hemispheres, focal cystlike white matter defects and focal or multifocal (susceptibility-related) residual signs of hemorrhage/hemosiderin deposition not related to arterial infarction as concordant MRI findings in all 6 patients. Conclusion COL4A1 mutations should be considered as differential diagnosis in children with history of pre-/perinatal stroke or cerebral hemorrhage, impairment of cognitive and motor development and epilepsy. Despite the heterogeneity of the clinical phenotype, typical MRI findings and co-morbidities can lead to the correct diagnosis. Epilepsy in our patients with COL4A1-mutations manifested in the first year of life; in the small collective of our ongoing study, valproic acid and vigabatrin were the most effective antiepileptic drugs.

Chorea in Non-Ketotic Hyperglycemia

Chorea is an involuntary, irregular, poorly patterned movement that is associated with a wide variety of illnesses. In this case, we describe a 71-year-old female who presented with choreiform movements after a change to her diabetes medication regimen. The patient was found to have non-ketotic hyperglycemia and was admitted to the hospital for insulin and rehydration. Once the patient’s blood glucose was controlled, her choreiform movements resolved. MRI showed no abnormal findings. In previous case reports, MRI showed hyperintense lesions in the putamen. Although the pathophysiology behind this finding is unclear, several mechanisms have been hypothesized including dopamine hypersensitivity and GABA depletion. We present this case in order to demonstrate the need to consider non-ketotic hyperglycemia in a patient with new onset choreiform movements without typical MRI findings.

Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case–control study

BackgroundPosterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the...

Prognostic factors for the recurrence of myxoid liposarcoma: 20 cases with up to 8 years follow-up

IntroductionMyxoid liposarcomas (MLS) are the second most common type of liposarcoma. Although some MRI findings are distinctively characteristics of MLS, the diagnosis can be tricky in tumors with a large portion of round cells (RC). Known predictors of an unfavorable outcome include age, tumor size, high RC content and positive resection margins. The goal of this retrospective study was to define prognostic factors for recurrence, with special emphasis on the percentage of RCs and medical care provided in a non-specialized center. Patients and methodsTwenty patients (11 women, 9 men) with a mean age of 44.3years (18–73) were reviewed after a mean of 55.9months. Six of these patients had been operated at a non-specialized center. The diagnostic MRI was read by a specialized radiologist and the resection procedures performed by two specialized surgeons. Tumors were labeled as either “pure myxoid liposarcoma” or “myxoid/round-cell liposarcoma”. The local recurrence-free survival rate and mortality rate were calculated. ResultsFifteen patients had undergone an MRI during the initial assessment. The typical MRI findings of MLS were present in four of them. The MRI suggested a non-specific lesion in the other 11 patients. After correlation with pathology findings, these tumors contained more than 5% round cells. The fourteen patients treated at our facility had undergone a biopsy, while none of the ones treated outside did. Five patients had R0 resection margins and 15 had R1 margins. Prognostic factors for recurrence consisted of age, tumor size >10cm, R1 resection margins, FNCLCC grade 2+R1 margins, medical care at a non-specialized center, and >5% round cells. There were eight local recurrences and three metastases (15%). Two patients died (90% overall survival rate). DiscussionThe risk of local recurrence was 3.86 times greater in this study when the tumor contained more than 5% RCs, which is consistent with published data. The MLS diagnosis was made only four times based on the initial MRI because misleading nature of high RC tumors. R1 resection margins are a risk factor for local recurrence. However, cases with R1 margins have a recurrence rate that is similar to R0 cases when the surgery is performed at a specialized cancer center. Treatment of MLS in a non-specialized center is a key negative prognostic factor. The reported rate of metastasis varies. Atypical extrapulmonary localizations are common, and often multifocal. MRI has been shown to be superior at detecting secondary lesions and some have suggested that a full-body MRI should be performed. ConclusionPrognostic factors for the recurrence of myxoid liposarcomas have been identified. MRI analysis is not definitive and must be supplemented by a biopsy.

MRI in NMO: How to differentiate from MS

Neuromyelitis Optica (NMO) is characterized by simultaneous or sequential acute transverse myelitis and optic neuritis. Spinal cord lesions extending over 3 or more vertebral segments are the typical MRI finding in NMO. Shorter MRI lesions can be found very early during relapse or in residual atrophic stages. Some of the lesions may appear hypointense on corresponding T1-weighted images which reflects sever inflammation with necrosis. T1-weighted hypointensities may help in differentiating NMO lesions from MS in spinal cord. “Snake-eye” or “owl-eye” sign a common feature of spinal artery ischemia has been reported to be transiently observed at an early stage of NMO. Brain MRI is initially normal in most patients with NMO but serial imaging may depict lesions in up to 85% of the patients at later stages. Brain lesions are usually nonspecific but may fulfill the Barkhof criteria for dissemination in space. Acute, large, edematous callosal lesions with a heterogeneous intensity occasionally develop in patients with NMO (marbled pattern). In contrast, in MS, callosal lesions are small, non-edematous, and the intensity was homogeneous in the acute phase and located at the lower margin of the corpus callosum. Multiple patchy enhancements with blurred margins (cloudlike enhancement) have been reported to be typical for NMO. Pencil-like ependymal enhancement is another type of enhancement around the anterior horns of lateral ventricles. Extensive hemispheric lesions, periependymal lesions surrounding the aqueduct, the third and fourth ventricles and brain stem lesions should raise the diagnosis of NMO. Actually NMO should be considered in any atypical lesion for MS in appropriate clinical settings. The extensive hemispheric lesions differed from those observed in regions of high AQP4 expression and were likely related to vasogenic edema; they sometimes looked like “spilled ink” and followed the white-matter tracts.

EVOLVING BRAIN LESION: CAAN'T MAKE A DIAGNOSIS

A 42-year-old man with longstanding type 1 diabetes presented with subjective memory difficulties. He was awaiting combined pancreas-kidney transplant for diabetic nephropathy. Assessment demonstrated no objective cognitive impairment and no focal neurological deficit. Initial MRI brain scanning revealed a focus of subtle abnormal high signal within the right fronto-parietal region, which on serial imaging became more prominent with extension into contralateral parietal and bilateral subcortical regions at one year. DWI and MRA were normal. Microhaemorrhages were seen on T2*. Nine months post-presentation he developed focal motor seizures. Given the concern regarding immunosuppression secondary to diabetes and chronic renal failure, together with the potential for further immunosuppression post-transplant, extensive screening for opportunistic infection and malignancy was undertaken but without diagnostic clarification. Brain biopsy was undertaken, with histological examination revealing striking deposition of amyloid-s consistent with cerebral amyloid angiopathy (CAA-As). CAA-As has a spectrum of clinical phenotypes and the usual mode of presentation is with spontaneous intracerebral haemorrhage. Typical MRI findings include cerebral microbleeds and haemorrhages, siderosis and leucoencephalopathy. Presentation as a focal, evolving, non-haemorrhagic lesion is rare. A review of similar cases will be presented and the implications of a diagnosis of CAA-As for potential transplant recipients discussed.

Enfermedad de Creutzfeldt-Jakob en el Perú: reporte de once casos

Creutzfeldt-Jakob disease (CJD) is a fatal neurological disease caused by pathological isoform of the human prion protein. Clinical features of six cases of the sporadic form of CJD with definitive diagnosis by histopathology, and five cases with probable diagnosis were reported in patients treated at the Peruvian National Institute of Neurological Sciences. The average age of onset in definite cases was 55.8 years and in probable cases was 59.6, mostly males. The average disease duration was 8.8 months. A typical EEG was found in 50% of definite cases and in 80% of probable. The 14-3-3 protein in cerebrospinal fluid was positive in a probable case, and typical MRI findings were observed in two probable cases. All cases studied had a typical clinical course of the disease, and it is considered as the first report of CJD in Peru.

DIAM Implantation for Degenerative Disc Disease

Introduction Lumbar disc degeneration (LDD) is among the most common causes of low back pain. Typical symptoms include axial low back pain, buttock pain, with or without radiation to posterior thighs or legs, and intolerance to upright positions. Several surgical treatment options are available, including intradiscal injections, intradiscal electrothermal therapy, discectomy, total disc arthroplasty, and fusion. Recently, implantation of interspinous process devices has been shown to decrease low back pain, and provide morphological alterations of the degenerative discs, resulting in satisfactory clinical outcomes. This study was conducted to review our results of using stand-alone DIAM implantation as the treatment for symptomatic LDD. Materials and Methods A total of 24 selected cases of LDD were treated surgically with stand-alone DIAM implantation. In 20 patients, the presenting symptoms were predominantly axial low back/buttock pain with little leg pain, while in 4 patients there was only axial pain. Motor weakness and sensory disturbance involving the corresponding nerve roots were present in eight cases. Three patients had undergone previous lumbar discectomy of the afflicted discs. Typical MRI findings included loss of height, signal changes, and/or annular tear of the discs. On the basis of Pfirrmann grading scale for disc degeneration, three cases were categorized as Grade II, and 21 cases as Grade III. Our exclusion criteria included intermittent claudication due to lumbar spinal stenosis, severe disc space collapse with Modic changes, greater than Grade II spondylolisthesis, facet ankylosis, and L5-S1 pathology. Provocative test with intradiscal injection of normal saline-induced concordant pain in all cases. Results All patients reported significant symptom relief after surgery, as reflected by VAS and ODI improvements. The final outcomes were excellent in 19, good in 2, fair in 2, and poor in 1 cases. Segmental flexion/extension mobility was maintained in 20, and restricted or lost in 2, of 22 cases with preoperative mobility. In the other two cases with no preoperative mobility, DIAM implantation did not change the status. MRI was repeated in the two cases showing fair, and the one case showing poor outcomes. In all of them, enlargement of neuroforamens at the implanted levels were found. In one fair case, disappearance of annular tear was observed. In the other fair case (L4-5 implantation), L5-S1 disc herniation was disclosed, and removed in a second operation. The case with poor outcome was diagnosed with depression, having concomitant multiple joint pain, dysmenorrhea, sleep disorder, despite normal findings on different exams ordered by different specialists. Conclusion In highly selected cases with symptomatic LDD, stand-alone interspinous DIAM implantation is effective for alleviation of symptoms, and stabilization of disc status. Disclosure of Interest None declared References Sandu N, Schaller B, Arasho B, Orabi M. Wallis interspinous implantation to treat degenerative spinal disease: description of the method and case series. Expert Rev Neurother 2011;11(6):799–807 Buric J, Pulidori M, Sinan T, Mehraj S. DIAM device for low back pain in degenerative disc disease : 24 months follow-up. Acta Neurochir Suppl (Wien) 2011;108:177–182 Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine 2001;26(17):1873–1878