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SummaryObjective Nephropathia epidemica (NE) is a haemorrhagic fever with renal syndrome (HFRS) caused by Puumala hantavirus (PUUV). Pituitary haemorrhage and hypopituitarism may complicate recovery from acute NE. Design Forty-seven of our recent cohort of 58 NE patients volunteered to be re-examined in order to estimate the burden of hormonal deficiency 4 to 8 years after the acute illness. Two patients had suffered from pituitary haemorrhage, but many others exhibited pituitary oedema during their acute infection. In this study, we searched for symptoms of hormonal deficiency, performed hormonal laboratory screening, and most patients underwent pituitary MRI examination. Results The pituitary size had diminished in all patients in whom MRI was performed (P

Objective There are concerns that not all costly advanced imaging is appropriate. However, studies about the appropriateness of magnetic resonance imaging (MRI) are sparse. The aim of this study was to review various MRI examinations done at a university hospital to determine whether there is inappropriate use. Methods Altogether 150 common MRIs (upper abdomen or liver, lumbar spine, knee, head and head of children performed under anaesthesia, 30 each) were reviewed consecutively. The referrals and corresponding patient files were analysed by senior radiologists and the indications of the examinations were compared to the referral criteria. Results Seven per cent of the examinations were deemed inappropriate. All the MRIs of the head done on children were indicated. One to three examinations in all other subgroups were not indicated. The most common appropriate indications were ambiguous hepatic, pancreatic or adrenal lesions, prolonged lower back pain, suspicion of meniscus rupture, brain malignancy and developmental disorder of a child, respectively. Conclusions Although the proportion of inappropriate examinations was not high; financial issues and the growing number of patients referred for MRI are of concern. Education and regular use of up-to-date referral guidelines could help to further improve appropriateness. Main Messages •Seven per cent of the MRI examinations analysed were inappropriate at a university hospital. •Everyday practices of a hospital may contribute to the level of appropriateness. •A survey of indications for previous MRI examinations might be helpful in various institutions.

Neurogenic pulmonary edema (NPE) is a well-recognized phenomenon after intracranial insult. In this study, we evaluated the predictors for NPE and its association with outcome in patients with intensive care unit-treated nontraumatic intracranial hemorrhage.This was a prospective, observational clinical study in a university-level intensive care unit. Clinical characteristics, level of consciousness, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were recorded on admission and the findings of primary head computed tomography were reviewed. A chest radiograph and arterial blood gas analysis were taken serially and NPE was determined as acute bilateral infiltrates in chest radiograph and hypoxemia. Echocardiography and cardiac and inflammatory markers were recorded. The 1-year outcome was assessed using the Glasgow Outcome Scale.NPE developed in 38 (35%) of the 108 patients included. Predictors for NPE were higher APACHE II score (≥20, odds ratio 6.17, P = 0.003) and higher interleukin-6 plasma concentration (40 pg/mL, odds ratio 5.62, P = 0.003). Of patients with 0, 1, or 2 predictors mentioned above, 4%, 37%, and 65% had NPE, respectively. NPE was associated with a higher 1-year mortality (37% vs 14%, P = 0.007, respectively), but with an unchanged functional outcome after 1 year (Glasgow Outcome Scale score 1-3, 53% vs 51%, P0.9).Predictors for NPE are the severity of disease defined by APACHE II scores and higher levels of systemic inflammatory mediators. NPE is associated with a higher 1-year mortality, but not with a poorer 1-year functional outcome.

The serum concentration of S100β protein reportedly predicts outcomes after brain injury. We examined the prognostic accuracy of S100β in patients with non-traumatic intracranial hemorrhage.This was a prospective, observational study of patients with non-traumatic intracranial hemorrhage treated in the intensive care unit at our university hospital. Computed tomography imaging findings and the level of consciousness on admission were recorded. Serum S100β concentration was measured serially during the first six days of admission. Patients with subarachnoid hemorrhage (SAH group) or intracerebral hemorrhage (ICH group) were analyzed separately. The 3-month and 1-year functional outcomes were assessed using the Glasgow Outcome Scale (GOS).Of 108 patients enrolled, 66 were included in the SAH group and 42 in the ICH group. High initial S100β concentration was associated with Glasgow Coma Score 3-6 on admission (SAH group 0.61 μg/L versus 0.15 μg/L, P=0.001 and ICH group 1.00 μg/L versus 0.42 μg/L, P=0.005). Initial S100β concentration correlated with ICH volume (rho=0.50, P0.001) and IVH Sum Score (rho=0.30, P=0.013). The thresholds for the initial S100β concentration with 100% specificity for poor outcome (GOS 1-3) were 1.40 μg/L for SAH and 1.76 μg/L for ICH group. ORs varied between 3.1 and 6.1 for S100β on poor outcome in the SAH group. Increasing S100β level during study period was associated with poor outcome in the SAH group.Serum S100β concentration corresponds with the severity of neurological insult and predicts poor outcome in patients with non-traumatic intracranial hemorrhage.

Traumatic brain injuries (TBI) in subjects with craniofacial fractures are usually diagnosed by emergency room physicians. We investigated how often TBI remains unrecorded in these subjects, and whether diagnostic accuracy has improved after the implementation of new TBI guidelines.All subjects with craniofacial fractures admitted to Oulu University Hospital in 1999 and in 2007 were retrospectively identified. New guidelines for improving the diagnostic accuracy of TBI were implemented between 2000 and 2006. Clinical symptoms of TBI were gathered from notes on hospital charts and compared to the recorded diagnoses at discharge. Logistic regression was used to identify independent predictors for TBI to remain unrecorded.Of 194 subjects with craniofacial fracture, 111(57%) had TBI, 40 in 1999 and 71 in 2007. Fifty-one TBIs (46%) remained unrecorded at discharge, 48 being mild and 3 moderate-to-severe. Subjects with unrecorded TBI were significantly less frequently referred to follow-up visits. Failures to record the TBI diagnosis were less frequent (29/71, 41%) in 2007 than in 1999 (22/40, 55%), but the difference was not statistically significant. The most significant independent predictor for this failure was the clinical specialty (other than neurology/neurosurgery) of the examining physician (p0.001). The subject's alcohol intoxication did not hamper the diagnosis of TBI.TBIs remain frequently unrecorded in subjects with craniofacial fractures. Recording of mild TBI slightly but insignificantly improved after the implementation of new guidelines.

Puumala hantavirus (PUUV) causes nephropathia epidemica (NE), a type of viral haemorrhagic fever with renal syndrome (HFRS). This febrile infection may affect the kidneys, central nervous system (CNS), and the eye. Acute illness is associated with increased tissue permeability and tissue oedema, and many patients experience reduced vision. The aim of this study was to explore the physiological events associated with the ocular features of acute NE.This was a prospective study of 46 NE patients who were examined during the acute infection and 1 month after hospitalization. Visual acuity, refraction, intraocular pressure (IOP), and ocular dimensions were evaluated. Cerebrospinal fluid and blood samples were collected, brain magnetic resonance imaging and electroencephalography were recorded, and HLA haplotype was analyzed. The degrees of tissue oedema and fluid imbalance were evaluated.CNS examinations did not reveal the source of the ocular changes in acute NE. The plasma C-reactive protein concentration correlated with the lens thickness and the IOP. The plasma creatinine level was associated with the change in anterior chamber depth. However, oliguric and polyuric patients displayed similar ocular findings. Patients positive for the DR3-DQ2 haplotype experienced the least diminished visual acuity.The level of systemic inflammation rather than CNS involvement appears to account for the ocular changes during acute PUUV infection, and the severity of kidney dysfunction may also have a significant role. In addition, the genetic properties of the host may well explain the ocular features of acute hantavirus infection.

BACKGROUND AND PURPOSE: While the number of CTA examinations is continually increasing compared with DSA examinations, there is little comparative dose information about the different imaging techniques. We compared patient radiation exposure resulting from diagnostic CTA and DSA examinations for both cerebral and cervicocerebral vessels. MATERIALS AND METHODS: An anthropomorphic phantom was irradiated by using typical diagnostic CTA and DSA setups and imaging parameters. For both imaging techniques, the imaging area of cerebral vessels included intracranial vessels only, while the imaging area of cervicocerebral vessels included both cervical and intracranial vessels from the aortic arch to the vertex. The effective dose was determined by using RPLDs. The DSA examination was simulated by using a biplane angiography system, and the CTA examination, by using a 64-row multidetector CT scanner. RESULTS: For the imaging of cerebral vessels, the effective dose according to ICRP 103 was 0.67 mSv for CTA and 2.71 mSv for DSA. For the imaging of cervicocerebral vessels, the effective dose was 4.85 mSv for CTA and 3.60 mSv for DSA. The maximum absorbed dose (milligray) for skin, brain, salivary glands, and eyes was 166.2, 73.5, 35.6, and 21.8 mGy for DSA and 19.0, 16.9, 20.4, and 14.8 mGy for CTA, respectively. The conversion factors from DAP and DLP to effective dose were calculated. CONCLUSIONS: The effective dose for CTA assessment of cerebral vessels was approximately one-fifth the dose compared with DSA. In the imaging of cervicocerebral vessels, the effective dose for CTA was approximately one-third higher compared with DSA.

The doses of radiation from computed tomography (CT) are relatively high, yet CT is being increasingly utilized. Furthermore, the radiation-induced lifetime risk of cancer mortality is higher at younger age. The purpose of this study was to find out whether previous CT examinations done on patients aged under 35 years were justified, and if not, whether there would have been other, more justifiable imaging modalities available. Fifty CT examinations of the head and 30 CT examinations each of the lumbar spine, cervical spine, abdomen, nasal sinuses and trauma were evaluated consecutively since the beginning of the year 2005 by using electronic patient files, the referral guidelines for imaging recommended by the European Commission and certain principles of classification. Seventy-seven per cent of the CT examinations of the lumbar spine, 36% of the head, 37% of the abdomen, 20% of the nasal sinuses and 3% of the cervical spine were unjustified. Most of these unjustified examinations could have been replaced by magnetic resonance imaging. In order to reduce utilization of ionizing radiation, both the referring practitioner and the radiologist responsible for the examination should carefully consider the justification for CT examinations and the possibility of using other imaging modalities.

Rationale and Objectives The aim of this study is to explore whether edema attenuated inversion recovery (EDAIR) sequences could be used to improve tumor contrast in contrast-enhanced low-field 0.23-Tesla magnetic resonance imaging (MRI) using 0.1 mmol/kg of gadolinium-based contrast agent. Materials and Methods Ten patients with brain tumors were examined by using the following contrast-enhanced sequences: T1-weighted spin echo, EDAIR with inversion time (TI) of 600 milliseconds, and EDAIR with TI of 800 milliseconds. Images were assessed both quantitatively and qualitatively. Results Results suggest that tumor contrast enhancement in low-field MRI can be improved without increasing contrast agent dose. EDAIR 600 appears to be optimal in most cases. Conclusions This inversion recovery sequence could be applicable as an additional sequence in the imaging of metastases in low-field MRI, as well as imaging of any other enhancing brain tumors or lesions in low-field MRI.

Electronic patient record (EPR) and picture archiving and communication systems (PACS) can be connected to wireless terminals which deliver information to the point of care. We present our experiences with mobile teleradiology using special type mobile phones: smartphones and personal digital assistants (PDA) with phone functions. According to the results, these terminals are feasible for emergency situations and mainly for evaluation of neurosurgical CT images. The article also describes the different experiences with GSM and GPRS mobile networks.

Rationale and objectives To introduce and evaluate a novel, image fusion-based technique that can be used to compare the findings of primary and control brain magnetic resonance imaging scans, with special attention to the differences found in this comparison. Materials and methods A new technique named “colored difference mapping” was applied to the brain examinations of five patients. The possible changes in the magnetic resonance imaging findings were analyzed by the colored difference mapping technique and by using conventional film reading and the results were compared. Results Colored difference mapping accurately depicts the differences between successive magnetic resonance images and reveals small changes that are difficult to perceive in a visual evaluation. Conclusion Colored difference mapping is suitable for comparison of images between two different radiologic examinations and helps to show even minimal changes in brain tissues.

Computed tomography provides a sensitive method for investigating skeletal muscle changes in neuromuscular diseases, but this method has not been applied to mitochondrial myopathies. We characterized the pattern of muscle involvement in patients with the 3243A>G mutation in mitochondrial DNA (mtDNA), the common MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes) mutation. Twenty-four patients, age 19–73 years, with 3243A>G were examined. Clinical evaluation included assessment of muscle strength and functional capacity. All the patients underwent muscle computed tomography, and muscle samples from 17 of them were examined for the presence of ragged red fibres and for the 3243A>G heteroplasmy. Venous blood lactate at rest and serum creatine kinase were determined. Clinical myopathy was found in six patients, while nine showed mild muscle weakness and nine had normal muscle function. The upper and lower limbs were equally affected, but the proximal muscles were more severely affected than the distal ones. CT revealed abnormalities in the muscles of 13 patients (54%; 95% confidence interval, 33–76%), including the six with clinical myopathy and seven without clinical myopathy. Myopathic changes were found most frequently in the pelvic muscles, with predominant involvement of the gluteus maximus. These data show that CT reveals frequent abnormal findings in the muscle of patients with the 3243A>G mtDNA mutation.Muscle CT is a useful adjunct to clinical evaluation in these patients.

Purpose: To evaluate the influence of the amount and distribution of blood on acute ventricular enlargement in subarachnoid hemorrhage (SAH). Material and Methods: In a retrospective study, non‐contrast computed tomography (CT) images of 180 patients with aneurysmal SAH were analysed by two neuroradiologists. The amount and distribution of the hemorrhage were scored, and prospective hydrocephalus was identified on the basis of acute CT images by calculating the cella media index, by measuring the width of the third ventricle, and by visual impression. Statistical analysis was done using the logistic regression model, analysis of variance, and chi‐square test. Results: The incidence of acute hydrocephalus was higher among the patients with blood distributed in the anterior, lateral, and basal regions (70.8%) than among the patients who did not have blood distributed in all three areas ( P=0.010). The proportion of acute hydrocephalus differed depending on the type of hemorrhage ( P Conclusions: A positive correlation was found between acute hydrocephalus and the amount of subarachnoid and, more importantly, intraventricular blood. This is consistent with the literature and confirms the current pathophysiologic concepts that the acute hydrocephalus following SAH is an obstructive form of hydrocephalus.

A wireless hand-held Webpad device was used to review a sample set of cranial computerized tomography (CT) studies to assess its diagnostic capabilities and its feasibility as a portable diagnostic workstation for radiology. The data-set consisted of 30 head CT studies of emergency cases. Two neuroradiologists and a senior radiologist participated in the evaluation of the portable workstation. They used a Web-based viewer that we developed, which provided all the major functionalities required for radiological image review. The reported radiological findings and diagnoses were compared with a gold standard, comprising a set of diagnoses previously formulated by a consensus panel of radiologists who had reviewed the original studies. The diagnoses made using the Webpad were correct (no major discrepancies) in 82 out of 90 interpretations (91%), which is comparable to the accuracy reported in image review with a conventional radiological workstation. The average total working time per diagnosis was 5 min 25 s (range 2–12 min). The simplicity of use of the system and its low cost make it suitable for distributing radiological studies within hospital facilities.

Computed tomography (CT) is the "gold standard" for detecting subarachnoid haemorrhage (SAH) and digital subtraction angiography (DSA) for visualising the vascular pathology. We studied retrospectively 180 patients with subarachnoid haemorrhage (SAH) who underwent first non-enhanced computed tomography (CT), then digital subtraction angiography (DSA) and finally operative aneurysm clipping. Our aim was to assess if the location of the ruptured aneurysm could be predicted on the basis of the quantity and distribution of haemorrhage on the initial CT scan.180 patients with SAH were retrospectively studied. All the CT and DSA examinations were performed at the same hospital. CT was performed within 24 hours after the initial haemorrhage. DSA was performed after the CT, within 48 hours after the initial haemorrhage. Two neuroradiologists, blind to the DSA results, analysed and scored independently the quantity and distribution of the haemorrhage and predicted the site of the ruptured aneurysm on the basis of the non-enhanced CT. DSA provided the location of the ruptured aneurysm. All the patients were operated upon, and the location of the ruptured aneurysm was determined.The overall reliability value (kappa-value) between the two neuroradiologists for locating all ruptured aneurysms was 0.780. The corresponding value for the right MCA was 0.911, that for the left MCA 0.877 and that for the AcoA 0.736. Not all of the kappa-values were calculated, either because the location of the rupture was constant or because the number of ruptures in the vessel was too small. Subarachnoid haemorrhage with a parenchymal hematoma is an excellent predictor of the site of the ruptured aneurysm with a statistical significance of p=0.003.The quantity and pattern of the blood clot on CT within the day of onset of SAH is a reliable and quick tool for locating a ruptured MCA or AcoA aneurysm. It is not, however, reliable for locating other ruptured aneurysms. Subarachnoid haemorrhage with a parenchymal hematoma is an excellent predictor of the site of a ruptured aneurysm.

The aim of this study was to analyze the patency of percutaneously inserted metallic stents in malignant biliary obstruction and to evaluate all the complications associated with the stents and the reinterventions needed.Thirty-nine patients with 42 malignant strictures were treated percutaneously with 55 metallic self-expandable stents. Forty-eight were Wallstents and seven were Memotherm stents. Twenty-five strictures were hilar, 16 were in the common bile duct, and one was in the hepaticojejunal anastomosis. The patients were followed until death and the mean follow-up was 6.4 months.Stent insertion was successful in 97% of the patients. Thirty percent had early complications (30 days), and as many as 66% had late complications, including stent occlusions, which were seen in 10 patients. The patency rates of patients with cholangio-carcinoma were significantly lower than those of the patients with other diagnoses. There was also a tendency toward obstruction with less dilation of the stents, Y, T or tandem-style stent placement, an increasing number of stents, longer strictures, and hilar strictures. Thirty-one percent of the patients alive after the first 30 days had late reinterventions.Although metallic stents offer an alternative in the palliation of malignant bile duct obstruction, there seem to be numerous early and late complications.

To determine whether the justification of CT examinations performed on young patients can be improved by various interventions and whether these have an effect on the total number of CTs performed.Specific interventions-education, guideline implementation and increased MRI capacity-were introduced at the Oulu University Hospital, Oulu, Finland, following a previous study demonstrating unjustified use of CT examination in young patients. In the present study, the justification of 177 CT examinations of the lumbar and cervical spine, head, abdomen, nasal sinuses and trauma performed on patients aged under 35 years in 2009 was analysed retrospectively by looking at requests and corresponding patient files. The indications of the examinations were compared with the referral guidelines recommended by the European Commission. Results from our previously published similar study carried out before the interventions were used as a reference.The proportion of justified CT examinations increased from 71% (141/200) in 2005 to 87% (154/177) in 2009 (p0.001), and in the lumbar spine group from 23% (7/30) to 81% (22/27) (p0.001). In the case of most of the unjustified examinations, MRI could have been performed instead. The total number of CT examinations carried out on young patients decreased by 7% (p=0.012) and in the lumbar spine group by 79% (p0.001).The implemented interventions decreased the number of CT examinations performed on young patients, and the justification of the examinations improved significantly.This study demonstrates that it is possible to reduce the number of various CT examinations and to improve their justification in young patients by regular education, guideline implementation and increased MRI capacity.

Purpose To evaluate the safety and efficacy of percutaneous aspiration and ethanol sclerotherapy as the sole treatment for symptomatic, nonneoplastic, congenital hepatic cysts. Patients and Methods In a prospective study, 59 symptomatic, congenital hepatic cysts in 25 patients were treated with ultrasound-guided percutaneous aspiration and ethanol sclerotherapy. Eleven patients had a solitary cyst, and 14 patients had polycystic liver disease. Mean follow-up was 4 years. Results Fifty-seven (97%) of 59 sclerotherapy procedures were technically successful, and there were no recurrences. Eight cysts in six patients disappeared totally. The mean diameter of the remaining 49 cysts decreased from 9 cm to 3 cm. At the last follow-up visit, 14 patients were asymptomatic, four had milder epigastric pain than before the treatment, and seven with polycystic liver disease had recurrent symptoms due to growth of nontreated cysts. No major complications occurred. Conclusion Percutaneous aspiration with ethanol sclerotherapy is a safe, effective, and minimally invasive treatment method for symptomatic congenital cysts. It is the initial treatment of choice for all patients with symptomatic congenital hepatic cysts.

The objective of this study was to assess the possibility of predicting histological characteristics of meningiomas on the basis of preoperative MRI and the correlation of the expression of vascular endothelial growth factor (VEGF) and collagen XVIII with histological parameters already established as predictive of the course of these tumors. Expression of VEGF and collagen XVIII as well as other histological characteristics was examined in meningioma tissues from 20 patients. Preoperative MRI, including dynamic imaging of contrast enhancement, was analyzed. Times to maximum enhancement and maximum intensity increase were noted from dynamic imaging. The relative intensity of the tumor in fluid-attenuated inversion recovery (FLAIR), T2-weighted and contrast enhanced T1-weighted images, as well as volumes of tumor and edema, was calculated. The edema-tumor volume ratio was defined as the edema index (EI). Both VEGF and collagen XVIII were expressed in all meningioma samples. Edema was present in 60 % of cases. The strongest correlation of VEGF expression was to EI. Among histological parameters, microvessel density (MVD) and cellularity correlated moderately with VEGF. Collagen XVIII expression correlated strongly with the maximal intensity increase after contrast agent administration (ρ = 0.71, P = 0.001) as well as with MVD and intensity of the meningioma on FLAIR images. Meningiomas with faster and more intense enhancement in dynamic studies, indicative of good tumor blood supply and permeability of vasculature, are associated with high levels of collagen XVIII and VEGF expression. Occurrence of peritumoral edema in meningiomas is strongly correlated with expression of VEGF.

We describe MR findings of a nasal glioma in a 5-week-old male infant with feeding difficulties and symptoms of respiratory distress. Endoscopic examination revealed a soft tissue mass in the nasal cavity. In T1- and T2-weighted images, the gyral structure of grey matter was visible. In T1-weighted images, a tissue component with a lower signal intensity equal to that of white matter was also well distinguishable. Edge enhancement of the tumour was due to the nasal mucosal epithelium covering the tumour. MR images were useful to rule out intracranial extension of the nasal cavity lesion and the brain, thus excluding the diagnosis of encephalocele. The lesion was excised and histologically characterized as heterotopic brain tissue.

Background Our aim was to characterize clinical properties and laboratory parameters in patients with or without cerebrospinal fluid (CSF) findings suggestive of central nervous system (CNS) involvement, and especially those who developed serious CNS complications during acute nephropathia epidemica (NE) caused by Puumala hantavirus (PUUV) infection. Methods A prospective cohort of 40 patients with acute NE and no signs of major CNS complications was analyzed. In addition, 8 patients with major CNS complications associated with NE were characterized. We collected data of CNS symptoms, CSF analysis, brain magnetic resonance imaging (MRI) results, electroencephalography (EEG) recordings, kidney function, and a number of laboratory parameters. Selected patients were evaluated by an ophthalmologist. Results Patients with a positive CSF PUUV IgM finding or major CNS complications were more often males (p < 0.05) and they had higher plasma creatinine values (p < 0.001) compared to those with negative CSF PUUV IgM. The degree of tissue edema did not explain the CSF findings. Patients with major CNS complications were younger than those with negative CSF PUUV IgM finding (52.9 vs. 38.5 years, p < 0.05). Some patients developed permanent neurological and ophthalmological impairments. Conclusions CNS and ocular involvement during and after acute NE can cause permanent damage and these symptoms seem to be attributable to true infection of the CNS rather than increased tissue permeability. The possibility of this condition should be borne in mind especially in young male patients.

Nineteen patients with 49 symptomatic non-neoplastic non-parasitic simple hepatic cysts were subjected to ultrasonographically guided percutaneous aspiration and temporary injection of 99% ethanol into the cyst. Small cysts were treated twice, the large ones three times at the same sitting. The volume of alcohol per injection varied from 20 to 100 ml, depending on the size of the cyst. A cure was usually achieved with one ethanol sclerotherapy treatment. Only minor side effects such as transient pain and temperature elevation occurred. Forty-seven of the 49 cysts could be treated adequately, and did not recur during a follow-up period af 12–40 months. The results indicate that aspiration an and ethanol sclerotherapy is the treatment of choice in patients with symptomatic non-neoplastic simple hepatic cysts or polycystic liver disease.

Puumala hantavirus (PUUV) causes a hemorrhagic fever with renal syndrome (HFRS) also called nephropathia epidemica (NE). Recent case reports and retrospective studies suggest that NE may damage the pituitary gland. Based on these observations, our goal was to explore the nature of this complication prospectively.A total of 58 hospitalized patients with acute NE volunteered to participate. Central nervous system (CNS) symptoms were recorded, cerebrospinal fluid (CSF) samples were collected, human leukocyte antigen (HLA) haplotype was analyzed, brain magnetic resonance imaging (MRI) was acquired, and electroencephalography (EEG) was recorded. Patients with abnormal pituitary MRI finding were examined by an endocrinologist.Most patients experienced CNS symptoms, and half of the CSF samples were positive for PUUV IgM, elevated protein level, or leukocyte count. CSF of patients negative for DR15(2)-DQ6 haplotype was less frequently affected. MRI revealed pituitary hemorrhage in two patients; these two patients suffered sudden loss of vision associated with headache, and they both developed hypopituitarism. Only one patient required long-term hormonal replacement therapy.CNS-related symptoms and inflammation in the CSF are common in acute NE. Genetic properties of the host may predispose to CNS involvement. It does seem that pituitary injury and subsequent hormonal insufficiency may complicate the recovery.

Background: Chronic hydrocephalus is a common sequela of subarachnoid hemorrhage (SAH). The technical procedure used to treat intracranial aneurysms, whether neurosurgical clipping or endovascular coiling, may lead to differences in the incidence of chronic posthemorrhagic hydrocephalus. Purpose: To compare the effects of early neurosurgical and early endovascular treatment on the development of chronic hydrocephalus in patients with SAH. Material and Methods: A retrospective study included 102 clipped and 107 coiled patients with aneurysmal SAH. Clinical condition at admission and shunt dependence were verified from patient data records. The initial and follow-up computed tomography (CT) images were reviewed, and the amount and distribution of blood and the occurrence of hydrocephalus were registered. The values of the cella media index and the width of the third ventricle were calculated. Statistical analysis of the data was performed. Results: No statistically significant differences in the incidence of chronic hydrocephalus or the need for shunting emerged between the treatment groups. After clipping 35% and after coiling 39% of the patients developed chronic hydrocephalus. Twenty-nine percent of the clipped and 31% of the coiled patients underwent a shunt operation. Conclusion: The treatment method used for acutely ruptured intracranial aneurysms, i.e., neurosurgical clipping or endovascular coiling, has no statistically significant effect on the development of chronic hydrocephalus.

Objectives: To investigate theoretically enhancement and optimal pulse repetition times for Gd-BOPTA and Gd-DTPA enhanced brain imaging at 0.23, 1.5, and 3.0 T. Methods: The theoretical relaxation times of unenhanced, conventional contrast agent (Gd-DTPA) and new generation contrast agent (Gd-BOPTA) enhanced glioma were calculated. Then, simulation of the signals and contrasts as a function of concentration and pulse repetition time (TR) in spin echo sequence was done at 0.23, 1.5, and 3.0 T. The effect of echo time (TE) on tumor-white matter contrast was also clarified. Three patient cases were imaged at 0.23 T as a test of principle. Results: Gd-BOPTA may give substantially better glioma-to-white matter contrast than Gd-DTPA but is more sensitive to the length of TR. These characteristics are accentuated at 0.23 T. Optimal TR lengths are shorter for Gd-BOPTA than for Gd-DTPA enhanced imaging at all field strengths. TR optimized for Gd-DTPA may thus give suboptimal contrast in Gd-BOPTA enhanced imaging. Higher enhancement with Gd-BOPTA is further accentuated by short TE. Conclusion: Appropriate TRs at 0.23 T appear to be approximately 300 to 400 milliseconds and 250 to 300 milliseconds, at 1.5 T 500 to 600 milliseconds and 400 to 450 milliseconds and at 3.0 T 550 to 650 milliseconds and 475 to 525 milliseconds using Gd-DTPA and Gd-BOPTA, respectively. For Gd-BOPTA enhanced imaging, it seems justified to optimize TR according to contrast and seek options like parallel excitation (Hadamard encoding) for increasing the number of slices and SNR.

Magnetic resonance imaging (MRI) has emerged as an essential tool of multiple sclerosis (MS) diagnosis and has opened up completely new prospects in MS research and treatment trials. It is a sensitive method that gives direct evidence of tissue pathology and has greatly increased our knowledge of MS. In clinical work, MRI is used to confirm and exclude the diagnosis of MS. The international recommendation is that every suspected MS patient should undergo at least one brain MRI. T2-weighted images are the standard tool in clinical work, and functional imaging methods are mainly used in MS research. The subtypes and the course of the disease cause variation in MRI findings. Here, we present a general overview of MR findings in MS.

The aim of this study is to explore whether edema attenuated inversion recovery (EDAIR) sequences could be used to improve tumor contrast in contrast-enhanced low-field 0.23-Tesla magnetic resonance imaging (MRI) using 0.1 mmol/kg of gadolinium-based contrast agent.Ten patients with brain tumors were examined by using the following contrast-enhanced sequences: T1-weighted spin echo, EDAIR with inversion time (TI) of 600 milliseconds, and EDAIR with TI of 800 milliseconds. Images were assessed both quantitatively and qualitatively.Results suggest that tumor contrast enhancement in low-field MRI can be improved without increasing contrast agent dose. EDAIR 600 appears to be optimal in most cases.This inversion recovery sequence could be applicable as an additional sequence in the imaging of metastases in low-field MRI, as well as imaging of any other enhancing brain tumors or lesions in low-field MRI.

BACKGROUND: Electrocardiographic (ECG) abnormalities are frequent in patients with intracranial insult. In this study, we evaluated the factors predisposing to the repolarization abnormalities, i.e., prolonged corrected QT (QTc) interval, ischemic-like ECG changes and morphologic end-repolarization abnormalities, and examined the prognostic value of these abnormalities in patients with subarachnoid and intracerebral hemorrhages requiring intensive care. METHODS: This was a prospective, observational clinical study in a university-level intensive care unit. Clinical characteristics, the level of consciousness, and findings in primary head computed tomography were recorded on admission. The study period was divided into three 2-day sections. In each section, a 12-lead ECG, transthoracic echocardiography, the results of standard blood electrolytes and cardiac troponin I, as well as the rate of vasoactive and sedative drug infusions were recorded. Repolarization abnormalities such as prolongation of the QTc interval (millisecond), ischemic-like ECG changes, and morphologic end-repolarization abnormalities (present/absent) were evaluated and analyzed. The 1-year functional outcome was determined using the Glasgow Outcome Score. RESULTS: During the 2-year study period, 108 patients were included in the study. Different repolarization abnormalities were frequent in both types of hemorrhage. Prolongation of the QTc interval was predisposed by female gender (β, 24.5; P = 0.010) and the use of propofol (β, 30.5; P = 0.001). The predisposing factor for ischemic-like ECG changes were male gender (odds ratio [OR], 5.9; P = 0.003) and for morphological end-repolarization abnormalities aneurysmatic bleeding (OR, 13.0; P = 0.002). Ischemic-like ECG changes were common, in 87/108 patients during the study period, and were associated with a poorer 1-year functional outcome (OR, 4.7; lower 95% confidence interval, 1.5; P = 0.010). CONCLUSIONS: Each repolarization abnormality has characteristic predisposing factors. Ischemic-like ECG changes are common and are associated with a poorer 1-year functional outcome. (Anesth Analg 2013;116:190–7)

• Thirty-one patients with posterior epistaxis refractory to nasal packing alone or in combination with surgical ligation (n=8) underwent diagnostic angiography and therapeutic embolization of the internal maxillary artery. Embolization resulted in the cure of epistaxis in 22 cases (71.0%). Of the nine failures (29.0%), seven underwent successful surgical clipping of the ethmoid arteries, and two were treated conservatively and died of their primary hematologic disease within 33 days. Late rebleeding occurred in two patients: one underwent reembolization and the other was treated surgically. No severe or permanent complications occurred. The results indicate that embolization is a feasible alternative to surgical intervention for patients with posterior epistaxis, and we recommend it as the treatment of choice in cases with high surgical risk or failure of prior arterial ligation. (Arch Otolaryngol Head Neck Surg.1993;119:837-841)