The woman without a history
The differential diagnosis for altered mental status (AMS) is broad and aetiological pathologies can arise from nearly all organs and body systems. Further complicating the matter, the altered patient is poorly suited to provide a comprehensive and accurate historical account. Thus, the physician must rely on collateral information, laboratories and imaging, and their own clinical suspicion. We present the case of a 75-year-old woman, found prone in her home with AMS, who was unable to provide a history. As her hospital stay evolved, we were forced to consider the entire breadth of possible causes of AMS. Eventually, the patient was found to have cerebral venous thrombosis, the significant extent of which is rarely reported. During the course of caring for the patient, we were reminded of the importance of remaining unbiased and unanchored while attempting to identify the source of the patient's ailment.
Bovine arch and carotid artery atherosclerosis: are they related?
OBJECTIVES: The prevalence of the "bovine" arch in the population is known (8-25%). However, its prevalence in patients with significant carotid atherosclerosis has never been investigated. Altered flow patterns or turbulence that may occur in these patients may play a causative role in the development of atherosclerotic lesions. The primary purpose of this study was to retrospectively compare the prevalence of aortic arch variants in patients with and without significant carotid artery atherosclerosis, as we hypothesize that carotid atherosclerosis may be more prevalent in patients with a bovine arch due to hemodynamic alterations. A secondary objective was to review radiologist reporting of arch anatomy. METHODS: Single-center, retrospective, case-control study in which 79 patients with hemodynamically significant carotid artery atherosclerosis who underwent computed tomography angiography, magnetic resonance angiography, or unenhanced computed tomography (CT) imaging including the aortic arch were identified. These patients were then compared with 95 randomly selected controls without carotid atherosclerosis that underwent similar imaging during the same time period. Images were independently reviewed by two blinded radiologists, who assessed arch anatomy as normal, bovine, or other variant. The original radiology reports were reviewed for reporting of arch anatomy. RESULTS: In controls, 70% had normal arch anatomy, and 24% had a bovine arch. Among patients with significant carotid disease, these numbers were 70% and 20%, respectively. There was no statistically significant difference between incidence of arch variants in subjects with and without carotid artery atherosclerosis (P=.97). There was good interreader agreement. Among patients with aortic arch anomalies, 20% of the original radiology reports did not mention arch anatomy. CONCLUSIONS: In our experience, percentage of bovine arch anomalies in patients with significant carotid atherosclerosis is not significantly different from those without disease. Clinicians should be aware of the high prevalence of arch anomalies, which can impact endovascular approach and management, and radiologists should be aware of the clinical importance of reporting such variants.
A better characterization of spinal cord damage in multiple sclerosis: a diffusional kurtosis imaging study
BACKGROUND AND PURPOSE: The spinal cord is a site of predilection for MS lesions. While diffusion tensor imaging is useful for the study of anisotropic systems such as WM tracts, it is of more limited utility in tissues with more isotropic microstructures (on the length scales studied with diffusion MR imaging) such as gray matter. In contrast, diffusional kurtosis imaging, which measures both Gaussian and non-Gaussian properties of water diffusion, provides more biomarkers of both anisotropic and isotropic structural changes. The aim of this study was to investigate the cervical spinal cord of patients with MS and to characterize lesional and normal-appearing gray matter and WM damage by using diffusional kurtosis imaging. MATERIALS AND METHODS: Nineteen patients (13 women, mean age = 41.1 +/- 10.7 years) and 16 controls (7 women, mean age = 35.6 +/- 11.2-years) underwent MR imaging of the cervical spinal cord on a 3T scanner (T2 TSE, T1 magnetization-prepared rapid acquisition of gradient echo, diffusional kurtosis imaging, T2 fast low-angle shot). Fractional anisotropy, mean diffusivity, and mean kurtosis were measured on the whole cord and in normal-appearing gray matter and WM. RESULTS: Spinal cord T2-hyperintense lesions were identified in 18 patients. Whole spinal cord fractional anisotropy and mean kurtosis (P = .0009, P = .003), WM fractional anisotropy (P = .01), and gray matter mean kurtosis (P = .006) were significantly decreased, and whole spinal cord mean diffusivity (P = .009) was increased in patients compared with controls. Mean spinal cord area was significantly lower in patients (P = .04). CONCLUSIONS: Diffusional kurtosis imaging of the spinal cord can provide a more comprehensive characterization of lesions and normal-appearing WM and gray matter damage in patients with MS. Diffusional kurtosis imaging can provide additional and complementary information to DTI on spinal cord pathology.
Variability of gross tumor volume delineation in head-and-neck cancer using PET/CT fusion, Part II: the impact of a contouring protocol
The purpose of this study was to assess the efficacy of a gross tumor volume (GTV) contouring protocol on interobserver variability between 4 physicians in positron emission therapy/computed tomography (PET/CT) treatment planning of head-and-neck cancer. A GTV contouring protocol for PET/CT treatment planning was developed utilizing 4 stages: Preliminary contouring on CT alone, determination of appropriate PET windowing, accurate image registration, and modification of CT contouring with correctly formatted PET/CT display and rules for modality disagreement. Two neuroradiologists and 2 radiation oncologists (designated as A, B, C, and D, respectively) were given a tutorial of PET/CT coregistered imaging individualized to their skill level, which included a step-by-step explanation of the protocol with clinical examples. Opportunities for questions and hands-on practice were given. The physicians were asked to re-contour 16 head-and-neck patients from Part I on PET/CT fusion imaging. Differences in volume magnitude were analyzed for statistical significance by analysis of variance (ANOVA) and paired t-tests (alpha<0.05). Volume overlap was analyzed for statistical significance using Wilcoxon signed-rank tests (alpha<0.05). Volume overlap increased significantly from Part I to Part II (p<0.05). One previously significant difference between physicians disappeared with the protocol in place. The mean fusion volume of Physician C, however, remained significantly larger than that of Physician D (p<0.01). This result is unchanged from Part I. The multidisciplinary contouring protocol significantly improved the coincidence of GTVs contoured by multiple physicians. The magnitudes of the volumes showed marginal improvement in consistency. Developing an institutional contouring protocol for PET/CT treatment planning is highly recommended to reduce interobserver variability
Variability of gross tumor volume delineation in head-and-neck cancer using CT and PET/CT fusion
PURPOSE: To assess the need for gross tumor volume (GTV) delineation protocols in head-and-neck cancer (HNC) treatment planning by use of positron emission tomography (PET)/computed tomography (CT) fusion imaging. Assessment will consist of interobserver and intermodality variation analysis. METHODS AND MATERIALS: Sixteen HNC patients were accrued for the study. Four physicians (2 neuroradiologists and 2 radiation oncologists) contoured GTV on 16 patients. Physicians were asked to contour GTV on the basis of the CT alone, and then on PET/CT fusion. Statistical analysis included analysis of variance for interobserver variability and Student's paired sample t test for intermodality and interdisciplinary variability. A Boolean pairwise analysis was included to measure degree of overlap. RESULTS: Near-significant variation occurred across physicians' CT volumes (p = 0.09) and significant variation occurred across physicians' PET/CT volumes (p = 0.0002). The Boolean comparison correlates with statistical findings. One radiation oncologist's PET/CT fusion volumes were significantly larger than his CT volumes (p < 0.01). Conversely, the other radiation oncologist's CT volumes tended to be larger than his fusion volumes (p = 0.06). No significant interdisciplinary variation was seen. Significant disagreement occurred between radiation oncologists. CONCLUSION: Significant differences in GTV delineation were found between multiple observers contouring on PET/CT fusion. The need for delineation protocol has been confirmed
Variability of gross tumor volume delineation in head-and-neck cancer using PET/CT fusion, part II: The impact of a contouring protocol [Meeting Abstract]
Neuroimaging abnormalities in a cohort of children identified at the time of their first unprovoked seizure [Meeting Abstract]
Neuroimaging abnormalities in children with an apparent first unprovoked seizure
OBJECTIVE: To determine the incidence and type of neuroimaging abnormalities in children presenting with a first seizure. METHODS: In a prospective observational study, 411 children with a first afebrile seizure were seen between 1983 and 1992. Imaging studies were performed in 218 (53%). For this analysis we examined the most sensitive neuroimaging study performed which included 159 computed tomography scans and 59 magnetic resonance imagings (MRI). RESULTS: Four children were found to have lesions requiring intervention (brain tumor in two, neurocysticercosis in two). The remaining 407 were enrolled in a follow-up study of children with a first unprovoked seizure. After a mean follow-up of >10 years, none have developed clinical evidence of a tumor. In these 411 children, 45 (21%) of 218 imaging studies were abnormal. The most common abnormalities were focal encephalomalacia (n=16) and cerebral dysgenesis (n=11). Although children with partial seizures were more likely to be imaged (64%) than children with generalized seizures (43%) (P<0.001), the fraction of abnormal imaging studies was similar in both groups. Six children with a normal neurological examination who were initially classified as cryptogenic were subsequently found to have errors of cerebral migration on MRI. The incidence of lesions requiring acute intervention in children presenting with a first seizure is low. A significant proportion will have neuroimaging abnormalities particularly on MRI. CONCLUSIONS: Neuroimaging should be considered in any child with a first seizure who does not have an idiopathic form of epilepsy
Patterns of central nervous system recurrence in patients with systemic human immunodeficiency virus-associated non-hodgkin lymphoma
BACKGROUND: Central nervous system involvement is a common manifestation of non-Hodgkin lymphoma (NHL) in human immunodeficiency virus (HIV)-infected individuals. The purpose of this study was to review the frequency and pattern of neurologic manifestation of lymphoma in a cohort of HIV-infected individuals with systemic NHL. METHODS: Sixty-two patients with HIV-associated systemic NHL received infusional cyclophosphamide, doxorubicin, and etoposide. Five patients with lymphomatous meningitis at presentation received whole brain radiation therapy plus intrathecal chemotherapy (ITC). Of the remaining 57 patients, prophylactic ITC was recommended only for those patients with lymphomatous bone marrow involvement and/or high grade histology (N = 31). RESULTS: Thirteen patients (21%) had histologically documented (N = 6) or presumed (N = 7) central nervous system involvement, including 7 patients (11%) with meningeal lymphoma discovered either at presentation (N = 5) or soon after diagnosis (N = 2), and 6 patients (10%) with cerebral mass lesions at the time of disease recurrence consistent with parenchymal brain involvement. Five of six parenchymal brain recurrences occurred in the setting of progressive systemic disease. Four of 7 patients (57%) with meningeal lymphoma detected at presentation (N = 5) or within 3 months of presentation (N = 2) responded to therapy and survived >1 year. Of the 26 patients assigned to receive no prophylactic ITC, no patient developed an isolated meningeal recurrence and 1 patient developed an isolated parenchymal brain recurrence. CONCLUSIONS: The findings of the current study suggest that in patients with HIV-associated systemic lymphoma, meningeal lymphoma is potentially curable, parenchymal brain recurrence usually occurs in the setting of uncontrolled systemic disease, and prophylactic ITC may not be necessary for patients with intermediate grade histology and uninvolved bone marrow
Effect of highly active antiretroviral therapy on the incidence of HIV-associated malignancies at an urban medical center
The widespread use of highly active antiretroviral therapy (HAART) since 1996 has led to a substantial decline in morbidity and mortality in patients infected with HIV, although its effect on the incidence of HIV-associated malignancies is unknown. We retrospectively reviewed the annual number of outpatient visits to our HIV clinic, inpatient admissions for HIV disease, and first admissions for patients with cancer and HIV disease at our center between 1990 and 1997. Between 1990 and 1995, there was a progressive increase in the annual number of admissions for HIV disease and HIV-associated cancers that paralleled the increasing HIV clinic volume. In 1997, however, the annual number of first admissions for Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma compared with 1995 decreased by 36% and 63%, respectively, despite a continued increase in the annual number of HIV clinic visits. Similar declines were also noted in the number of new cases of biopsy-confirmed KS and primary central nervous system (CNS) lymphoma. In contrast, there was no decrease in the number of first admissions for patients with HIV infection and other cancers not typically associated with HIV infection. These findings suggest a declining incidence of HIV-associated malignancies since the introduction of HAART