MRI Views Research Articles

Myasthenia Gravis as a Presenting Feature in a Patient With Hepatocellular Carcinoma: A Case Report

Myasthenia gravis (MG) as a presenting feature of extrathymic tumors are rarely reported. Here, we present a case of hepatocellular carcinoma (HCC) presented with MG. A 66-year-old Thai man presented to King Chulalongkorn Memorial hospital in September 2017 with weakness of his neck and legs. He also had trouble in swallowing and his voiced changed. The severity of those symptoms varied during a day while progressed over the past six months. Physical examination revealed weakness of neck muscle and the proximal muscle of extremities. Fatigability and enhanced ptosis were also observed. Electromyography showed a reproducible decremental response with repetitive nerve stimulation. High level of AChR-IgG (17.9 nmol/L) was compatible with a diagnosis of MG. The chest CT revealed no thymoma. However, the abdominal CT (figure 1) showed cirrhotic features with a 5.1x3.1 cm arterial enhancing and rapid venous washout mass in hepatic segment VIII invading segmental branches of right portal vein, representing the typical radiologic characteristics of HCC. The alpha-fetoprotein was 455 IU/mL. Serum immunologic test were negative for hepatitis B and C. The controlled attenuation parameter measured by transient elastography was 271 dB/m. The final diagnosis was fatty liver with cirrhosis grading Child-Pugh class A with HCC Barcelona Clinic Liver Cancer (BCLC) stage C and MG. The weakness improved after a treatment with intravenous immunoglobulin. Other medications were oral prednisolone 30 mg/d and pyridostigmine 240 mg/d which could be gradually tapered over time. Meanwhile, HCC was treated with two sessions of transarterial radioembolization (TARE) with Yttrium-90. The follow-up abdominal MRI (figure 2), 6 weeks after the 2nd TARE, demonstrated a decrease in size of both the HCC and the tumor thrombus in right portal vein. Several studies have been reported a high incidence of extrathymic malignancies with or without thymoma in MG patients, especially in the older age group. The pathophysiologic mechanism, even inconclusive, is suggested to be a paraneoplastic syndrome. However, there is no association between MG and any specific cancers. Approximately ten percent of these malignancies, with a rare report of HCC, present simultaneously with the MG. This case could be considered as the paraneoplastic MG, as an initial presentation, in a patient with advanced stage HCC. However, their associations require further investigations.2405_A Figure 1. The axial view of abdominal CT showed a 5.1x3.1 cm hypodensity mass in hepatic segment VIII (figure 1A; white arrow) with arterial enhancement in the arterial phase (figure1B) and rapid washout in the portovenous and delay phase (figure 1C and 1D, respectively) representing a typical radiologic features of HCC according to AASLD criteria.2405_B Figure 2. The axial view of the follow-up abdominal MRI (T1 dynamic phase) showed a decrease in size of HCC, 1.4x2.2 cm, in hepatic segment VIII (figure 2A; white arrow) without arterial enhancement in the arterial phase (figure 2B), representing responsiveness after TARE. Ring enhancement was observed in the portovenous and delay phase (figure 2C and 2D, respectively) representing fibrous tissue following TARE.

A Common Presentation of Right Upper Quadrant Pain in an Uncommon Disease

The presentation of right upper quadrant abdominal pain is common, non—specific and challenging to diagnose. Right upper quadrant (RUQ) pain can be benign but may also signal serious pathology. Early diagnosis is key to preventing possible complications. This case aims to highlight a presentation of RUQ pain in a young male which heralded a more sinister pathology. A previously healthy 36year—old male presented with one—week of intermittent fevers and progressive sharp RUQ pain with chills, night sweats, early satiety and fatigue. Initial assessment was significant for HR 116, RUQ tenderness with guarding, no rebound or organomegaly. Laboratory findings were only significant for lactate 11.08mg/dL. Cultures were negative, AFP was normal. HIV, HBV and HCV were negative.Abdominal ultrasound revealed heterogeneous large right hepatic lobe mass suggestive of hemorrhage, hepatic adenoma, metastasis, fibrolamellar hepatocellular carcinoma (HCC) or hepatic abscess. MRI with contrast had similar findings with large non—enhancing geographic regions, T2—hyperintense and T1—hypointense, consistent with necrosis or blood products. MRI was suggestive of atypical HCC, fibrolamellar HCC, angiosarcoma or metastases; hepatic adenoma unlikely in the absence of risk factors. CT—guided biopsy revealed hepatic neoplasm favoring adenoma with atypical findings evidenced by immunostaining, diffuse strong glutamine synthetase staining and no nuclear beta—catenin staining, positive serum amyloid A, and retained LFABP. Glutamine synthetase staining was concerning for beta—catenin invasion. He underwent a right hepatic lobectomy, with pathology finding of hepatic adenoma, and no recurrence at 1—year follow—up. Hepatocellular adenomas (HCA) are rare, benign tumors which occur mostly in women and are strongly associated with the use of estrogens, anabolic and androgenic steroids. There are no specific diagnostic serologic or imaging studies. The new Bordeaux HCA subtype classification is based on genetic and phenotypic characteristics and provides insight into the pathological and radiological diagnosis and clinical management. Complications such as rupture, hemorrhage and malignant transformation to HCC increase mortality markedly. Mortality is low when recognized and treated early. It is, therefore, an important differential to consider in a patient with RUQ pain in the presence of a liver mass with no underlying cirrhosis. The absence of risk factors does not exclude the diagnosis.3020_A.tif Figure 1: Abdominal ultrasound: Large heterogeneous right hepatic lobe mass with suggestion of internal hemorrhage.3020_B.tif Figure 2: Contrast—MRI, coronal and axial views: marked enlargement of the right hepatic lobe secondary to a large mass with intrahepatic blood products suggesting rupture/hemorrhage3020_C.tif Figure 3: Liver biopsy histology: Hepatocellular neoplasm, favor adenoma with atypical findings. Diffuse strong glutamine synthetase staining, serum amyloid A positive, retained LFABP, no nuclear beta—catenin staining and noncontributory reticulin special stain

An Abortive Hepatocellular Carcinoma Presenting as Obstructive Jaundice

This is the case of an 80 year old Hispanic man that came to the emergency room due to right upper quadrant discomfort and yellowing of the skin for the past weeks. He also reported dark colored urine, clay color stools and a 30 pound weight loss. He was taking apixaban for chronic atrial fibrillation and had a prior cholecystectomy due to gallstones. He was jaundiced, the liver edge was palpable, and had right upper quadrant tenderness. Laboratory tests revealed hemoglobin of 11.1 mg/dL, thrombocytosis of 389 x 103, prolonged PT at 18.4 sec, bilirubin in 25 mg/dL, alkaline phosphatase of 1,079 u/L and elevated hepatic enzymes consistent with a cholestatic pattern. An abdominal CT with intravenous contrast demonstrated intrahepatic biliary ductal dilation with prominent distention of the common hepatic duct. A soft tissue density measuring 1.8 cm x 1.3 cm, was observed within the proximal common bile duct, which appeared to be the cause of the obstruction (Figure 1). An ERCP revealed a large filling defect in distal common bile duct. After sphincterotomy, a balloon sweep helped remove a fibrinogenous longitudinal mass with blood clots resolving the obstruction (Figure 2). Histologic examination of aborted cast and the immunoperoxidase studies, which showed strong reaction for hepatocyte specific antigen and were negative to CDX-2, CEA, CK-20, were compatible with hepatocellular carcinoma (HCC). Work up for pre-existing liver disease was negative for viral hepatitis and autoimmune markers. Subsequent hepatic contrast MRI demonstrated a large infiltrative mass replacing the liver and extending into the inferior vena cava and proximal right atrium (Figure 3). HCC is one of the most common cancers in the world. Obstructive jaundice due to HCC is rare. It has been described in approximately 0.5-9% of all cases. This presentation is known as icteric type hepatocellular carcinoma (IHCC). There are several mechanisms for which obstruction can occur in IHCC; tumor compression, hemobilia, migration of the tumor debris or by tumor growth into the bile ducts. IHCC is associated with a poor prognosis, although depends on stage of disease, and the location and extension of tumor thrombi. In view of this rare presentation experts referred to IHCC as a special type of HCC. We report an uncommon case, diagnosed by ERCP, of an abortive HCC presenting as obstructive jaundice. In our case, the use of anticoagulation may have contributed to this unusual presentation.Figure: Axial view, with prominent distention of the common hepatic duct of 1.8 cm x 1.3 cm, with portions of central intra-hepatic duct soft tissue density most compatible with cholangiocarcinoma. There is an area of prominent irregular mass like bulging of the hepatic contour noted hepatic dome measuring approximately 5.2 x 6.9 x 4.4 cm and concerning for peripheral neoplastic mass.Figure: White Fibrinogenous material extracted after balloon sweep and send for analysis.Figure: Axial MRI view showing arge infiltrating hepatic mass extending into the inferior vena cava and proximal right atrium.

The “second ulnar groove”, a MRI sign suggesting a previous palmar luxation of the ulna at the distal radioulnar joint

IntroductionA cortical lined impaction on the radiodorsal side of the ulnar head may be at the origin of a “second ulnar groove” (SUG). The goal of this article is to illustrate this MRI sign, prompting for further investigation of the distal radioulnar joint (DRUJ). Hence associated soft tissue pathology may be detected, which may lead to instability. Material and methodsFollowing an anterior luxation of the ulna at the DRUJ a second cortical lined groove in a previously normal distal ulna was discovered. A data base review from January 2008 to August 2016 of the axial FS PD-TSE WI 1.5T MRI views of 1.716 patients was accomplished in search of similar bone defects. ResultsEight patients with previous severe wrist trauma presented with a similar posttraumatic ulnar bone defect. The preceding anterior luxation at the DRUJ was only clearly demonstrated in five patients. However, two more patients had a residual anterior subluxation. Different imaging techniques are discussed and the differential diagnosis is well illustrated. ConclusionsThe type of trauma, the specific location and the morphology of a second ulnar groove, all compatible with a sequel of an anterior luxation of the ulna at the DRUJ, should lead to a further specific clinical and MRI revaluation of the DRUJ.

A retrospective review of cases preoperatively diagnosed by radiologic imaging as cavernous venous malformations

ABSTRACTThe purpose of this study is to examine orbital lesions identified on preoperative radiologic imaging as cavernous venous malformations (CVMs), identify their imaging characteristics, and determine if these may help differentiate CVMs from other intraorbital masses. An IRB–approved retrospective chart review over 30 years was undertaken identifying lesions “consistent with cavernous hemangioma” on radiologic studies, which were subsequently surgically resected with a tissue diagnosis. All radiologic images (CT and MRI) obtained preoperatively were re-reviewed by a single masked neuroradiologist. The pattern of contrast enhancement on sequential MRI views was used to determine whether the enhancing characteristics helped identify CVMs compared to other intraorbital masses. Fifty-seven orbital lesions consistent with a CVM were identified on imaging. Fourteen (25%) of them were resected, of which nine (64%) were found to be CVMs on pathologic examination. Five (36%) were found to be a different lesion, most commonly schwannoma (21%). On imaging, CVMs tended to display heterogeneous progressive enhancement, whereas other tumors, in particular schwannomas, enhanced at their maximum level immediately. Based on these characteristics, on re-review, the masked neuroradiologist was able to differentiate a CVM versus other tumors for all 14 imaging cases. This study suggests that examining the pattern of contrast enhancement may help to correctly differentiate a CVM from other isolated, encapsulated orbital lesions on CT/MR imaging.

Collapsed membranes within pelvic cyst: What is the diagnosis?

Key Clinical MessageCollapsed membranes and daughter cysts are pathognomonic for hydatid cysts on imaging. The comma‐shaped lesions, visible within the hydatid cyst in sagittal view of MRI, are collapsed membranes. Although primary hydatid cyst of pelvic cavity is rare, clinicians should remember to include hydatid cysts in differential diagnosis of pelvic cysts.

A Simple Approach for Relatively Automated Hippocampus Segmentation from Sagittal View of Brain MRI

In this paper, we present a relatively automated method to segment the hippocampus in t1 weighted magnetic resonance images that can be acquired in the routine clinical setting. This paper describes a simple approach for segmenting the hippocampus automatically from sagittal view of brain MRI. Large datasets of structural MR images are collected to quantitatively analyze the relationships between brain anatomy, disease progression, treatment regimens, and genetic influences upon brain structure..This method segments the hippocampus without any human intervention for few slices present mid position in the total volume. Experimental results using this method show a good agreement with the manual segmented gold standard. These results may support the clinical studies of memory and neurodegenerative disease.

Blood Supply and Skeletal Muscle Infarction

BACKGROUND: Muscle infarction is a rare complication of spontaneous ischemic necrosis occurring in skeletal muscle. It is particularly common in patients with diabetes who have impaired sugar regulation. However, muscle infarction is frequently misdiagnosed due to varied clinical manifestations. METHODS: We presented 3 cases of muscle infarction reported during April 2009 to April 2014. After a comprehensive literature review, we selected 147 muscle infarction cases from the literature, first investigating the relationships between type of muscle blood supply and infarcted muscle. RESULTS: The result indicated that muscle infarction 25.85 % belonged to type I vascular supply and 61.21% belonged to type II vascular supply, according to the definition by Mathes and Nahai (Figure 1, Table 1).Figure 1: Upper: Axial view of MRI with hyper intense signal. Lower: Coronal view with infarcted gastrocnemius and subcutaneous edematous change.Table 1: Vascular type of infarcted muscles.Muscle infarction 25.85 % belonged to type I vascular supply and 61.21% belonged to type II vascular supply, according to the definition by Mathes and Nahai. Total: 147, type I: 25.85%, type II: 61.21%, type III: 0, type IV: 6.8% Note: Classification by Mathes and Nahai5 VI: Vastus intermedius, VM: Vastus medialis , VL:Vastus lateralis , RF: Rectus femoris BF: Biceps femoris CONCLUSIONS: Poor glucose regulation, intense exercise without adequate hydration, vascular disease, and type I and II muscular blood supply were critical predisposing factors. For preventing muscle infarction, we recommend strict glucose regulation and a gradual increase in exercise with adequate hydration.

Selection of indications and surgical treatment of basilar invagination with atlantoaxial dislocation

To evaluate the indications and effect of surgical treatment of basilar invagination (BI) with atlantoaxial dislocation (AAD) on the basis of retrospective analysis of the clinical and imaging data of patients. Consecutive 21 patients with BI and AAD were surgically treated in Department of Spinal Surgery, The First Affiliated Hospital of Xinjiang Medical University from July 2000 to December 2013. There were 10 males and 11 females, aged from 7 to 59 years, with a mean of 36.4 years. The clinical symptoms and signs was recorded, and preoperative imaging examination including anteroposterior, lateral, dynamic films, MRI, CT and 3-dimensional reconstruction views of cervical spine were performed to identify the series. All cases were treated with operation. Neurological function was assessed by JOA scale and NDI score before, after surgery and at final follow-up. The postoperative X-rays, MRI or CT was taken to observed the results of decompression, fixation and fusion. There were 5 cases operated by posterior approach, combined anterior and posterior approach in 16 cases, atlantoaxial fixation in 2 cases, occipitocervical fixation in 19 cases. The average operation time was 200 mins, blood loss was 230 ml. Except for 2 death cases, 19 cases were followed up, the followed-up was arranged from 13 to 42 months, with an average of 21.6 months. Compared with preoperative parameters (7.8±1.3), the postoperative scores of JOA decreased significantly (14.1±0.5) and at the final follow-up (16.2±0.7) (P<0.05); compared with preoperative parameters (65.7±11.2), the postoperative scores of NDI decreased significantly (28.2±9.6) and at the final follow-up (22.7±7.4) (P<0.05) and no significant difference in JOA or NDI score existed between post-operation and last follow-up (P>0.05). The perioperative complications was discovered in 6 cases, including infection in 2 cases, cerebrospinal fluid (CSF) leakage in 2 cases, respiratory dysfunction, cleft palate in 1 case, respectively. BI with AAD can be treated by anterior, posterior or combined approaches. Careful evaluation, proper selection of indications and prevention of perioperative complications are important consideration to ensure the success of surgery.

Classification and surgical treatment of basilar invagination

Objective To present a new classification of basilar invagination (BI) and evaluate guiding use and effect of the classification for the treatment of BI. Methods Consecutive 34 patients with BI were surgically treated in our department from July 2000 to June 2013. There were 17 males and 17 females, aged from 7 to 59 years (mean, 34.5 years). The clinical symptoms and signs were recorded, and preoperative imaging examination including anteroposterior, lateral, dynamic X-rays, MRI, CT and 3-dimensional reconstruction views of cervical spine were performed to identify the series. 34 patients with BI were associated with anomalies including atlantooccipital assimilation in 21 cases, C2-3 fusion in 16 cases, and atlantoaxial dislocation in 24 cases. According to with or without atlantoaxial dislocation, BI was classified into Type I with dislocation in 24 cases and Type II without dislocation in 10 cases. Type I was divided into reducible subtype A in 6 cases and irreducible subtype B in 15 cases under the condition of skull traction. Type I was performed with reduction by traction or release between C1-2 through anterior or posterior approach, while Type II with decompression by resection abnormal structures through anterior or anteroposterior approach. All patients were underwent posterior instrumentation and fusion. The postoperative X-rays, MRI or CT was taken to observed the results of decompression, fixation and fusion. Neurological function was assessed by JOA scale and Ranawat's score. Results The average operation time was 210 min, and blood loss was 240 ml. Except for 2 death cases, 32 cases were followed up, and the followed-up was ranged from 11 to 37 months (mean, 17.4 months). JOA scores increased from 8.4 to 14.6 with 71.1% of recovery. The excellent and good rate was 72.4%. According to Ranawat's score, preoperative score was class II in 11 cases,class IIIA in 17 cases and class IIIB in 6 cases, while postoperative score was class I in 20 cases, class II in 11 cases and class IIIA in 1 case. The perioperative complications was present in 9 cases, including infection in 3 cases, cerebrospinal fluid (CSF) leakage in 2 cases, respiratory dysfunction in 2 cases, vertebral artery injury and cleft palate in 1 case. Conclusion The new classification of BI can effectively guide and schedule the treatment. Careful evaluation,operation and prevention of perioperative complications are important to ensure the success of surgery. Key words: Skull base; Atlanto-occipital joint; Atlanto-axial joint; Dislocations; Spinal fusion

Effect of Corticosteroids on Facial Function after Cerebellopontine Angle Tumor Removal: A Double-Blind Study versus Placebo

The aim of this study was to assess the effect of corticosteroids administered intra- and postoperatively on the occurrence of facial palsy after a cerebellopontine angle (CPA) tumor resection, and to investigate pre- and intraoperative prognostic factors. A multicenter, prospective, randomized, double-blind and versus-placebo study was conducted between 2006 and 2010. Three hundred and ten patients operated on for a CPA tumor (96% vestibular schwannomas, 4% miscellaneous) were included by five participating centers. The population was stratified into patients with small (≤15 mm CPA on axial MRI views) and large tumors. In each group, patients were randomized to receive corticosteroid (1 mg/kg/day i.v. methylprednisolone intraoperatively and at postoperative days 1-5) or placebo. Steroids did not affect the facial function at postoperative days 1, 8 and 30 in patients with small or large tumors as evaluated by House and Brackmann grading.

Characteristics and surgical results of the distal type of cervical spondylotic amyotrophy.

Cervical spondylosis that causes upper-extremity muscle atrophy without gait disturbance is called cervical spondylotic amyotrophy (CSA). The distal type of CSA is characterized by weakness of the hand muscles. In this retrospective analysis, the authors describe the clinical features of the distal type of CSA and evaluate the results of surgical treatment. The authors performed a retrospective review of 17 consecutive cases involving 16 men and 1 woman (mean age 56.3 years) who underwent surgical treatment for the distal type of CSA. The condition was diagnosed on the basis of cervical spondylosis in the presence of muscle impairment of the upper extremity (intrinsic muscle and/or finger extension muscles) without gait disturbance, and the presence of a compressive lesion involving the anterior horn of the spinal cord, the nerve root at the foramen, or both sites as seen on axial and sagittal views of MRI or CT myelography. The authors assessed spinal cord or nerve root impingement by MRI or CT myelography and evaluated surgical outcomes. The preoperative duration of symptoms averaged 11.8 months. There were 14 patients with impingement of the anterior horn of the spinal cord and 3 patients with both anterior horn and nerve root impingement. Twelve patients were treated with laminoplasty (plus foraminotomy in 1 case), 3 patients were treated with anterior cervical discectomy and fusion, and 2 patients were treated with posterior spinal fixation. The mean manual muscle testing grade was 2.4 (range 1-4) preoperatively and 3.4 (range 1-5) postoperatively. The surgical results were excellent in 7 patients, good in 2, and fair in 8. Most of the patients in this series of cases of the distal type of CSA suffered from impingement of the anterior horn of the spinal cord, and surgical outcome was fair in about half of the cases.

Missed cervical disc bulges diagnosed with kinematic magnetic resonance imaging.

To determine if adding flexion and extension MRI studies to the traditional neutral views would be beneficial in the diagnosis of cervical disc bulges. Five hundred patients underwent MRI in neutral, flexion and extension positions. The images were analyzed using computer software to objectively quantify the amount of disc bulge. Compared to the neutral position, cervical disc bulges were significantly increased in the extension position (P < 0.05), but on flexion position, there was no significant difference (P > 0.05). For patients without or <3 mm of disc bulge in neutral, 2.97% demonstrated an increase in bulge to ≥3 mm bulge in flexion, and 16.41% demonstrated an increase to ≥3 mm bulge in extension. For patients in the neutral view that had a baseline disc bulge of 3-5 mm, 3.73% had increased bulges to ≥5 mm in flexion and 11.57% had increased bulges to ≥5 mm in extension. A significant increase in the degree of cervical disc bulge was found by examining extension views when compared with neutral views alone. Kinematic MRI views provide valuable added information, especially in situations where symptomatic radiculopathy is present without any abnormalities demonstrated on traditional neutral MRI.

The new diagnostic methods of CADASIL as differential diagnosis of HDLS

Both hereditary diffuse leukoencephalopathy with axonal spheroids (HDLS) and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) are autosomal dominant white matter diseases. First symptoms of HDLS are cognitive decline or dementia, while those of CADASIL are migraine or ischemic infarcts. Family histories of young patients with stroke are important, because most of patients with CADASIL have these family histories. Temporal pole lesions are specific for CADASIL. However, some of the patients have no such lesions. We should differ CADASIL from non-CADASIL by evaluation of family history or the other MRI findings such as confluent external capsular lesions or multiple white matter medullary infarcts. Coronal views of MRI are useful for differentiating ischemic lesions from demyelinated lesions, even if horizontal views of MRI give little information. In addition, evaluation of immunohistochemical staining of Notch3 by frozen skin samples is useful for diagnosis. We discovered the methods of detecting light microscopic findings of GOM in frozen section. To reveal the pathogenesis of CADASIL, it is indispensable to analyze the chemical nature of GOM by histochemical stainings. We are going to analyze coexist proteins or materials in small arterial granular degeneration by proteomics of LC/ MS/ MS.

FLAIR fornix hyperintensity in VGKC-related autoimmune encephalitis

A 52-year-old man presented with progressive fatigue, drowsiness, weight loss, and memory impairment associated with left-sided temporal lobe seizures. Brain MRI revealed increased bilateral FLAIR signal in the hippocampus, amygdala, mammillary bodies, hypothalamus and fornix (Figs. 1, 2). Blood analysis showed normal CRP, TSH, vitamin B1 and B12 levels. Routine immunological screening, and HIV and syphilis serology were negative. Anti-voltage-gated potassium channel (VGKC) antibodies were positive (463 pmol/l; normal range 0–100 pmol/l), in the absence of antiganglioside antibodies, NMDA/TPO/ GAD antibodies and other paraneoplastic antibodies. CSF analysis showed oligoclonal bands in the absence of other abnormalities. Brain FDG-PET revealed bilateral frontal, parietal and temporal hypometabolism (all equally involved). Whole-body FDG-PET, thoraco-abdominal– pelvic CT and testicular echography were normal. Oral antiepileptic treatment (valproic acid 500 mg bid) led to seizure freedom. Important clinical improvement after corticosteroid treatment (60 mg od for 1 month, followed by tapering during 3 months) was seen, in the presence of persistent MRI abnormalities (although increased signal became less severe) 4 months later. After 1 year of followup, no clinical relapse occurred, and thoraco-abdominal– pelvic CT and whole-body FDG-PET remained normal. A diagnosis of VGKC-related autoimmune, probably nonparaneoplastic, encephalitis was made. Autoimmune-mediated encephalitis can involve several brain areas with notably frequent involvement of limbic system structures (referred to as limbic encephalitis) including the hippocampus, amygdala and the mammillary bodies [1, 2]. MRI (together with FDG-PET) is probably the most adequate imaging technique to reveal abnormalities in these structures. MRI abnormalities due to autoimmune-mediated encephalitis are best seen on FLAIR sequences as an increased signal. To the best of our knowledge, despite radiological involvement of other limbic substructures and associated brain areas (e.g., the hypothalamus), fornix signal changes have never been reported in autoimmune encephalitis. The fornix is an important fiber bundle or projection bundle within the limbic system explaining probably its involvement in our patient. The limbic system includes territories of the diencephalon (the epithalamus, hypothalamus, subthalamic zona incerta), telencephalon (the septal and preoptic regions, hippocampus and some adjacent cortical areas, amygdala, the bed nucleus of the stria terminalis), and mesencephalon. Fornix involvement has been described in multitude other diseases [3]. The fornix is a compact fiber bundle connecting the hippocampus with the hypothalamus and various other structures. Its anterior–posterior orientation makes coronal MRI views particularly interesting. Because of the close proximity of the fornix to structures containing CSF, FLAIR imaging is of special interest to visualize fornix signal abnormalities. Neuropathological findings in autoimmune limbic encephalitis are non-specific, including gliosis, perivascular lymphocyte infiltration and microglial activation. In our patient, it is unclear if signal changes of the fornix were secondary (e.g., due to edema or Wallerian degeneration) D. Renard (&) D. Ratiu Department of Neurology, CHU Nimes, Hopital Caremeau, Place du Pr Debre, 30029 Nimes Cedex 4, France e-mail: dimitrirenard@hotmail.com

SAT0432 Effectiveness of oral corticosteroid on gait in patients with narrow lumbar canal syndrome: Randomized, controlled, double-blind study

BackgroundLumbar canal stenosis mainly affects adults in the 5th decade of life and has a negative impact on quality of life. One of the most frequent complaints is claudication during...

Management of distal rectal cancer: results from a national survey

Owing to the complexity of distal rectal cancer its management requires a multidisciplinary approach. The diagnosis and the response after neoadjuvant chemoradiotherapy are not easy to assess and therefore the surgical approach is heterogeneous. The purpose of this survey is to evaluate the experiences of members of the Italian Society of Surgery in diagnosis and treatment strategies for rectal cancer and compare it with international practice. A questionnaire was devised comprising 18 questions with 11 sub-items making a total of 29 questions and submitted online to all the 2,500 members of the SIC starting from July 2010. The survey was completed in June 2011. The overall response rate was 17.8% (444). The majority of the Italian surgeons' responses were in line with the international consensus reflecting the complex management of distal rectal cancer. Other opinions, especially those on staging, diverge from the common view of MRI being the gold standard in the assessment of loco-regional diffusion of the disease and on the superiority of FDG PET-CT versus CT for systemic staging. The timing for the re-staging and for surgery following neoadjuvant chemoradiotherapy does not reflect the international opinion. Italian surgeons are also exposed to the common difficulties encountered internationally in the management of distal rectal cancer. Probably, the implementation of an Italian rectal cancer registry and of many national and international multicentre studies may improve the management of rectal cancer in Italy.

Effectiveness of Percutaneous Transforaminal Adhesiolysis in Patients with Lumbar Neuroforaminal Spinal Stenosis

Background: Lumbar foraminal spinal stenosis (LFSS) is a narrowing of the bony exit of a nerve root, which causes mechanical compression of spinal nerve roots. Low back pain and/or leg pain, and possibly neurogenic claudication, may result due to mechanical neural compression. Transforaminal epidural steroid injections (TFESIs) are commonly used for treating LFSS. Patients refractory to TFESIs may benefit from percutaneous epidural adhesiolysis. Objective: Our intent was to assess transforaminal adhesiolysis (TFA) as treatment for LFSS, analyzing patient response by severity of stenosis and evaluating the short-term effectiveness of TFA. Study Design: Prospective study. Methods: Following IRB approval, 35 patients with LFSS were enrolled, all of whom underwent magnetic resonance imaging (MRI) of the lumbar spine. Sagittal MRI views were evaluated to grade the severity of LFSS. TFA was routinely conducted in the operating room. One hour after the procedure, each patient received 6 mL of 10% sodium chloride, infused over 30 minutes, with monitoring. Posttreatment outcomes were determined at 2 weeks and 3 months using a 5-point patient satisfaction scale. To test predictive value, patients were stratified by response (improvement versus no improvement). Results: Improvement (defined as little pain, moderate pain, or no pain) was observed in 25 patients (71.4%) at 2 weeks and in 22 patients (62.8%) at 3 months following the procedure. Among patients showing improvement, those with Grade 3 spinal stenosis outnumbered those with Grade 2. At the 3-month follow-up, no statistically significant correlations between pain relief and the grade of LFSS was evident. Limitations: Secondary outcomes were not measured and the follow-up period was relatively brief. Conclusion: Short-term results indicate that percutaneous TFA is an effective treatment for LFSS, although therapeutic outcomes and the severity of LFSS showed no correlation. Key words: Lumbar, foraminal stenosis, adhesiolysis, effectiveness.

Multimodality imaging in biochemical recurrence of prostate cancer: Utility of 18F-NaF PET/CT in early detection of metastasis

A 54-year-old male with biopsy proven Gleason 9 prostate cancer presented with rapidly increasing serum PSA level of 12.4 ng/ml and PSA doubling time <1 month after radical prostatectomy. Conventional imaging scans (chest, abdomen and pelvis CT and 99mTc-MDP bone scintigraphy) were obtained which identified a single equivocal mildly sclerotic and active lesion in T8 vertebral body (Fig. 1). The patient was then enrolled in an ongoing prospective clinical imaging trial designed to assess the diagnostic utility of 18F-FDG PET/CT and 18F-NaF PET/CT in men with biochemical recurrence of prostate cancer and negative or equivocal standard imaging. While 18F-FDG PET/CT was negative, 18F-NaF PET/CT demonstrated numerous randomly distributed fluoride avid lesions in the skeleton (cervical/thoracic/lumbar spine, bilateral acetabuli pelvis, right clavicle) compatible with skeletal metastases (Fig. 2). Follow-up MRI of the spine confirmed the bony lesions (see Fig. 1). Patient was then started on androgen deprivation therapy (bicalutamide/leuprolide acetate) and radiotherapy to a painful area in lower-thoracic spine (3250 cGy to T7–T11) after which his PSA declined to 0.6 ng/ml. Follow-up 18F-NaF PET/CT showed increase in sclerosis on CT and decline in NaF uptake at sites of skeletal metastases. Conventional bone scintigraphy and CT are standard in the imaging evaluation of men with suspected metastatic disease based on rising serum PSA level. However, when available, 18F-NaF PET/CT should be considered since it may be useful in early detection of occult skeletal metastases as clearly demonstrated here in our case.1–3 Fig. 1 Initial imaging evaluation of a man with biochemical relapse of prostate cancer: (A) equivocal 99mTc MDP bone scan, (B) equivocal sagittal view of thoracic spine CT, (C) sagittal view of follow-up thoracic spine MRI (performed after 18F-NaF PET/CT) demonstrating ... Fig. 2 Demonstration of widespread osseous metastatic disease with 18F-NaF PET/CT: maximum intensity projection images of 18F-NaF PET/CT (A) at baseline, (B) at 6 months after start of therapy, (C) transaxial CT and fused 18F-NaF PET/CT appearance of a lesion ...

A novel in vivo method for lung segment movement tracking

Knowledge about lung movement in health and disease is sparse. Current evaluation methods, such as CT, MRI and external view have significant limitations. To study respiratory movement for image guided tumour diagnostics and respiratory physiology, we needed a method that overcomes these limitations. We fitted balloon catheters with electromagnetic sensors, and placed them in lung lobes of ventilated pigs. The sensors sensed their position at 40 Hz in an electromagnetic tracking field with a precision of ∼0.5 mm. The method was evaluated by recording sensor movement in different body positions and at different tidal volumes. No ‘gold standard’ exists for lung segment tracking, so our results were compared to ‘common knowledge’. The sensors were easily placed, showed no clinically relevant position drift and yielded sub-millimetre accuracy. Our measurements fit ‘common knowledge’, as increased ventilation volume increased respiratory movement, and the right lung moved significantly less in the right than the left lateral position. The novel method for tracking lung segment movements during respiration was easy to implement and yielded high spatial and temporal resolution, and the equipment parts are reusable. It is easy to implement as a research tool for lung physiology, navigated bronchoscopy and radiation therapy.