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Background: Hepatocellular carcinoma (HCC) is a prevalent tumor with high mortality rates. Computed tomography (CT) is crucial in the non-invasive diagnosis of HCC. Recent advancements in artificial intelligence (AI) have shown significant potential in medical imaging analysis. However, developing these AI algorithms is hindered by the scarcity of comprehensive, publicly available liver imaging datasets., Objectives: This study aims to detail the tools, data organization, and database structuring used in creating HepatIA, a medical imaging annotation platform and database at a Brazilian tertiary teaching hospital. HepatIA supports liver disease AI research at the institution., Material and Methods: The authors collected baseline characteristics and CT scans of 656 patients from 2008 to 2021. The database, designed using PostgreSQL and implemented with Django and Vue.js, includes 692 CT volumes from a four-phase abdominal CT protocol. Radiologists made segmentation annotations using the OHIF medical image viewer, incorporating MONAI Label for pre-annotation segmentation models. The annotation process included detailed descriptions of liver morphology and nodule characteristics., Results: The HepatIA database currently includes healthy individuals and those with liver diseases such as HCC and cirrhosis. The database dashboard facilitates user interaction with intuitive plots and histograms. Key patient demographics include 64% males and an average age of 56.89 years. The database supports various filters for detailed searches, enhancing research capabilities., Conclusion: A comprehensive data structure was successfully created and integrated with the IT systems of a teaching hospital, enabling research on deep learning algorithms applied to abdominal CT scans for investigating hepatic lesions such as HCC., Competing Interests: Declaration of competing interest The authors B.A.R., L.G.R.V., and A.C.M.C. are co-founders of Machiron SA. FMUSP, HCFMUSP, and Machiron SA. have established a collaborative partnership, with the terms of this arrangement having been reviewed and approved by the University of São Paulo in accordance with its conflict-of-interest policies. Meanwhile, L.C.F., J.M.C.F., L.S.L.N., M.R.M.S.F., C.C.L., C.H.N., G.G.C., F.J.C., and S.K.O. have declared no competing interests., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Dizziness and vertigo, frequently associated with cerebrovascular origins, pose a substantial challenge in emergency medical settings due to their potential to be associated with severe underlying conditions. Sudden-onset dizziness, in particular, may be an early indicator of critical events such as stroke or transient ischemic attack. This comprehensive review encompasses the differential diagnosis of central causes of dizziness and vertigo, emphasizing the crucial role of imaging modalities in the accurate detection and assessment, including cerebrovascular diseases, inflammatory disorders, infections, and other conditions such as vestibular migraine and cervical spondylosis. It highlights the significance of advanced imaging techniques, particularly magnetic resonance imaging and computed tomography in identifying and distinguishing these conditions., (Copyright © 2024. Published by Elsevier Inc.)

There is currently no efficacious intervention for preventing post-traumatic epilepsy (PTE). Preclinical studies support the potential use of anticholinergics for this condition. The purpose of this study was to evaluate the effects of biperiden as an intervention for preventing PTE. A randomized, double-blinded clinical trial was conducted at HC/FMUSP between 2018-2022. Adults with acute traumatic brain injury (TBI) were randomly assigned to receive biperiden or placebo, for 10 days. The primary outcome was the incidence of PTE while the secondary outcomes included the frequency of seizures, the frequency of any adverse events and mortality after 24 months. The study was powered at a planned enrolment of 132 patients. The trial began in January 2018 and was halted by researchers on March 2020 (and terminated in December 2022) in the face of the global COVID-19 pandemic. Overall, 123 participants were randomized and 112 contributed with data for modified mITT analysis, being that 61 (49.5%) participants completed the 24-month follow-up consult. Data analysis indicated lack of evidence of biperiden for either, the incidence of post-traumatic epilepsy (2.6, 95%CI, 0.65-10.57; p = 0.170) or the mortality rate (1.57, 95%CI, 0.73-3.38; p = 0.248). The frequency of late post-traumatic seizures was higher for biperiden group (2.03, 95%CI = 0.912-3.1597; p <0.001). The present study suggests that there was insufficient evidence regarding the effect of biperiden in preventing PTE after TBI, which underpins the need for larger studies. Clinical trial registration: ClinicalTrials.gov, identifier: NCT01048138., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Foresti, Garzon, de Moraes, Valeriano, Santiago, dos Santos, Longo, Baise, Andrade, Susemihl, Leite, Naffah Mazzacoratti, Paiva, de Andrade, Teixeira and Mello.)

Soccer players are at risk of suffering cranial injuries in the short and long term. There is growing concern that this may lead to traumatic brain injury in soccer players. Magnetic resonance spectroscopy (MRS) is an analytical method that enables the measurement of changes in brain metabolites that usually occur before significant structural changes. This study aimed to use MRS to compare variations in brain metabolite levels between retired soccer players and a control group. Twenty retired professional soccer players and 22 controls underwent magnetic resonance imaging, including MRS sequences and Mini-Mental State Examination (MMSE). Metabolite analysis was conducted based on absolute concentration and relative ratios. N-acetyl-aspartate, choline, glutamate, glutamine, and myoinositol were the metabolites of interest for the statistical analysis. Retired soccer players had an average age of 57.8 years, whereas the control group had an average age of 63.2 years. Median cognitive evaluation score, assessed using the MMSE, was 28 [26-29] for athletes and 29 [28-30] for controls ( p  = 0.01). Uni- and multi-variate analyses of the absolute concentration of metabolites (mM) between former athletes and controls did not yield any statistically significant results. Comparison of metabolites to creatine ratio concentrations did not yield any statistically significant results. There were no changes in concentrations of brain metabolites that indicated brain metabolic changes in retired soccer players compared with controls., Competing Interests: Matheus Rozalem Aranha was provided paid consultancy for Veranex., (© Lucas Lopes Resende et al., 2023; Published by Mary Ann Liebert, Inc.)

Background : Depressive symptoms have been associated with cognitive impairment after stroke, and women may be specifically affected. Objective : The aim of this study was to investigate gender-specific characteristics in the relationship between changes in depression severity and changes in cognitive performance after stroke. Methods : We prospectively evaluated 73 patients without a previous history of depression in the first and fourth months after a first ischemic stroke. The severity of depressive symptoms was assessed using the 31-item version of the Hamilton Rating Scale for Depression, and executive function, attention, working memory, and verbal fluency were assessed using a neuropsychological battery. Results : We included 46 (63.0%) men and 27 (36.9%) women, with mean ages of 55.2 (SD ± 15.1) and 46.8 (SD ± 14.7) years, respectively. We found significant improvement in the digit span forward and Stroop dots from month 1 to month 4 post stroke for both men and women. Women, but not men, presented a correlation between changes in phonemic verbal fluency and changes in the 31-item version of the Hamilton Rating Scale for Depression scores. Improvement in depression was correlated with improvement in verbal fluency, and worsening in depression was correlated with worsening in verbal fluency. Conclusions : Our results suggest that women might be more vulnerable to the relationship between depressive symptoms and cognitive performance, and improvement of depression may be necessary for women's improvement in phonemic verbal fluency from the first to the fourth month after a stroke. We did not adjust the results for multiple comparisons. Thus, our findings might be considered preliminary, and confirmatory studies, also focusing on specific characteristics of women that could explain these differences, are warranted.

Background: The coronary calcium score (CAC) measured on chest computerized tomography is a risk marker of cardiac events and mortality. We compared CAC scores in two multiethnic groups without symptomatic coronary artery disease: subjects in the chronic phase after stroke or transient ischemic attack and at least one symptomatic stenosis ≥50% in the carotid or vertebrobasilar territories (Group athero ) and a control group (Group control )., Methods: In this cross-sectional study, Group athero included two subgroups: Group ExtraorIntra , with stenoses in either cervical or intracranial arteries, and Group Extra&Intra , with stenoses in at least one cervical and one intracranial artery. Group control had no history of prior stroke/transient ischemic attacks and no stenoses ≥50% in cervical or intracranial arteries. Age and sex were comparable in all groups. Frequencies of CAC ≥100 and CAC > 0 were compared between Group athero and Group control , as well as between Group ExtraorIntr , Group Extra&Intra , and Group control , with bivariate logistic regressions. Multivariate analyses were also performed., Results: A total of 120 patients were included: 80 in Group athero and 40 in Group control. CAC >0 was significantly more frequent in Group athero (85%) than Group control (OR, 4.19; 1.74-10.07; p = 0.001). Rates of CAC ≥100 were not significantly different between Group athero and Group control but were significantly greater in Group Extra&Intra ( n = 13) when compared to Group control (OR 4.67; 1.21-18.04; p = 0.025). In multivariate-adjusted analyses, "Group athero " and "Group Extra&Intra " were significantly associated with CAC., Conclusion: The frequency of coronary calcification was higher in subjects with stroke caused by large-artery atherosclerosis than in controls., Competing Interests: RS has received honoraria related to consulting, research and or speaker activities from: Amgen, Aché, Astra Zeneca, Esperion, Kowa, Merck, Novo-Nordisk, PTC, Pfizer, and Sanofi/Regeneron. MB has received speaker fees from GE healthcare. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 de Araújo, Santos, Bittencourt, Dantas, Oshiro, Nomura, Bor-Seng-Shu, Oliveira, Leite, Martin, Alves, Silva, Silva and Conforto.)

Background: Obesity is a disease that may involve disrupted connectivity of brain networks. Bariatric surgery is an effective treatment for obesity, and the positive effects on obesity-related conditions may be enhanced by exercise. Herein, we aimed to investigate the possible synergistic effects of Roux-en-Y Gastric Bypass (RYGB) and exercise training on brain functional networks., Methods: Thirty women eligible for bariatric surgery were randomly assigned to a Roux-en-Y gastric bypass (RYGB: n = 15, age = 41.0 ± 7.3 years) or RYGB plus Exercise Training (RYGB + ET: n = 15, age = 41.9 ± 7.2 years). Clinical, laboratory, and brain functional connectivity parameters were assessed at baseline, and 3 (POST3) and 9 months (POST9) after surgery. The 6-month, three-times-a-week, exercise intervention (resistance plus aerobic exercise) was initiated 3 months post-surgery (for RYGB + ET)., Results: Exercise superimposed on bariatric surgery (RYGB + ET) increased connectivity between hypothalamus and sensorial regions (seed-to-voxel analyses of hypothalamic connectivity), and decreased default mode network (DMN) and posterior salience (pSAL) network connectivity (ROI-to-ROI analyses of brain networks connectivity) when compared to RYGB alone (all p-FDR < 0.05). Increases in basal ganglia (BG) network connectivity were only observed in the exercised training group (within-group analyses)., Conclusion: Exercise training is an important component in the management of post-bariatric patients and may improve the hypothalamic connectivity and brain functional networks that are involved in controlling food intake., Trial Registration: Clinicaltrial.gov: NCT02441361., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

The temporomandibular joint can be affected by various conditions, such as joint dysfunction, degenerative changes, inflammatory processes, infections, tumors, and trauma. The aim of this pictorial essay is to help radiologists identify and describe the main findings on magnetic resonance imaging evaluation of the temporomandibular joint, given that the correct diagnosis is essential for the appropriate treatment of patients with temporomandibular joint disorders.

Background: Headache is the most frequent symptom of cerebral venous thrombosis (CVT) but there is limited information about the frequency and phenotype of headache, weeks to months after cerebral venous thrombosis (post-cerebral venous thrombosis headache, PCH)., Objective: To assess the frequency, characteristics and predictors of PCH., Methods: In this cross-sectional study, the frequency and characteristics of PCH were assessed in cerebral venous thrombosis survivors. Patients were interviewed between six months and five years after the cerebral venous thrombosis diagnosis. Clinical and imaging characteristics at the time of cerebral venous thrombosis diagnosis, as well as history of headache prior to cerebral venous thrombosis were compared in subjects with (Group PCH ) and without PCH (Group control )., Results: Subjects (n = 100; 82% women) were assessed, on average, at 1.1 ± 1.6 years of follow-up. PCH was present in 59% of the patients, phenotypes of tension-type-like headache were present in 31/59 (52.6%) and of migraine-like headache in 16/59 (27.1%). History of primary headache prior to cerebral venous thrombosis was significantly more common (OR: 6.4; 95% CI: 1.7-36.3) in Group PCH (33.9%) than in Group control (7.3%)., Conclusion: PCH was present in more than half of the patients. History of prior headache may be a risk factor for PCH. Prospective studies are required to confirm these findings and determine mechanisms, as well as interventions for prevention and treatment of PCH.

Background: Diffuse axonal injury (DAI) is a frequent mechanism of traumatic brain injury (TBI) that triggers a sequence of parenchymal changes that progresses from focal axonal shear injuries up to inflammatory response and delayed axonal disconnection., Objective: The main purpose of this study is to evaluate changes in the axonal/myelinic content and the brain volume up to 12 months after TBI and to correlate these changes with neuropsychological results., Methods: Patients with DAI (n = 25) were scanned at three time points after trauma (2, 6, and 12 months), and the total brain volume (TBV), gray matter volume, and white matter volume (WMV) were calculated in each time point. The magnetization transfer ratio (MTR) for the total brain (TB MTR), gray matter (GM MTR), and white matter (WM MTR) was also quantified. In addition, Hopkins verbal learning test (HVLT), Trail Making Test (TMT), and Rey-Osterrieth Complex Figure test were performed at 6 and 12 months after the trauma., Results: There was a significant reduction in the mean TBV, WMV, TB MTR, GM MTR, and WM MTR between time points 1 and 3 (p < .05). There was also a significant difference in HVLT-immediate, TMT-A, and TMT-B scores between time points 2 and 3. The MTR decline correlated more with the cognitive dysfunction than the volume reduction., Conclusion: A progressive axonal/myelinic rarefaction and volume loss were characterized, especially in the white matter (WM) up to 1 year after the trauma. Despite that, specific neuropsychological tests revealed that patients' episodic verbal memory, attention, and executive function improved during the study. The current findings may be valuable in developing long-term TBI rehabilitation management programs., (© 2022 The Authors. Brain and Behavior published by Wiley Periodicals LLC.)

Background: Diffuse axonal injury occurs with high acceleration and deceleration forces in traumatic brain injury (TBI). This lesion leads to disarrangement of the neuronal network, which can result in some degree of deficiency. The Extended Glasgow Outcome Scale (GOS-E) is the primary outcome instrument for the evaluation of TBI victims. Diffusion tensor imaging (DTI) assesses white matter (WM) microstructure based on the displacement distribution of water molecules., Objective: To investigate WM microstructure within the first year after TBI using DTI, the patient's clinical outcomes, and associations., Methods: We scanned 20 moderate and severe TBI victims at 2 months and 1 year after the event. Imaging processing was done with the FMRIB software library; we used the tract-based spatial statistics software yielding fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) for statistical analyses. We computed the average difference between the two measures across subjects and performed a one-sample t-test and threshold-free cluster enhancement, using a corrected p-value < 0.05. Clinical outcomes were evaluated with the GOS-E. We tested for associations between outcome measures and significant mean FA clusters., Results: Significant clusters of altered FA were identified anatomically using the JHU WM atlas. We found increasing spotted areas of FA with time in the right brain hemisphere and left cerebellum. Extensive regions of increased MD, RD, and AD were observed. Patients presented an excellent overall recovery., Conclusions: There were no associations between FA and outcome scores, but we cannot exclude the existence of a small to moderate association.

Background: Brain abnormalities are a concern in COVID-19, so we used minimally invasive autopsy (MIA) to investigate it, consisting of brain 7T MR and CT images and tissue sampling via transethmoidal route with at least three fragments: the first one for reverse transcription polymerase chain reaction (RT-PCR) analysis and the remaining fixed and stained with hematoxylin and eosin. Two mouse monoclonal anti-coronavirus (SARS-CoV-2) antibodies were employed in immunohistochemical (IHC) reactions., Results: Seven deceased COVID-19 patients underwent MIA with brain MR and CT images, six of them with tissue sampling. Imaging findings included infarcts, punctate brain hemorrhagic foci, subarachnoid hemorrhage and signal abnormalities in the splenium, basal ganglia, white matter, hippocampi and posterior cortico-subcortical. Punctate brain hemorrhage was the most common finding (three out of seven cases). Brain histological analysis revealed reactive gliosis, congestion, cortical neuron eosinophilic degeneration and axonal disruption in all six cases. Other findings included edema (5 cases), discrete perivascular hemorrhages (5), cerebral small vessel disease (3), perivascular hemosiderin deposits (3), Alzheimer type II glia (3), abundant corpora amylacea (3), ischemic foci (1), periventricular encephalitis foci (1), periventricular vascular ectasia (1) and fibrin thrombi (1). SARS-CoV-2 RNA was detected with RT-PCR in 5 out of 5 and IHC in 6 out 6 patients (100%)., Conclusions: Despite limited sampling, MIA was an effective tool to evaluate underlying pathological brain changes in deceased COVID-19 patients. Imaging findings were varied, and pathological features corroborated signs of hypoxia, alterations related to systemic critically ill and SARS-CoV-2 brain invasion., (© 2022. The Author(s).)

Background: Despite enormous advances in the diagnosis and treatment of ischemic stroke over the past decades, the extent of "standard" investigation to define its causes is heterogeneous. Young patients often undergo a myriad of diagnostic tests in developed countries, but the cost-effectiveness of this approach is uncertain., Objectives: Our main goal was to compare the frequencies of ischemic stroke of undetermined and determined etiologies in young patients with "complete" or "incomplete" investigation according to either a stepwise or an extensive protocol., Methods: Data from 143 young patients with ischemic stroke were reviewed. For each patient, available data were assessed by means of a stepwise and an extensive protocol of investigation. We compared the frequencies of ischemic stroke of undetermined and determined etiology according to "complete" or "incomplete" investigation according to each protocol., Results: Completeness of investigation led to a significant increase in determination of stroke etiology when a stepwise approach but not an extensive protocol was applied., Conclusions: These results suggest that ordering an extensive workup to all young patients does not enhance the capability of determining causes of ischemic stroke. Evidence-based guidelines to define pathways of investigation and consensus about the interpretation of tests are deeply needed., Competing Interests: None

Some drugs and medications can precipitate immune system deregulations, which might be confused with recurrent demyelinating diseases, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMO), exacerbations of an existing disease, neoplastic lesions or other conditions. In this narrative review we describe some of the most relevant drugs and medications associated with iatrogenic demyelination. The anthelminthic agent levamisole is a frequent cocaine adulterant and can precipitate an exacerbated immune response attacking the central nervous system (CNS). High-efficacy multiple sclerosis (MS) drugs might induce a selective CNS immunosuppression, making it susceptible for opportunistic infections that course with demyelination, such as progressive multifocal leukoencephalopathy. Sometimes, the interruption of a high-efficacy drug to treat MS can induce a rapid CNS reentry of lymphocytes, exacerbating demyelinating processes and triggering rebound syndromes. Furthermore, selective cytokines inhibition, such as anti-TNFα agents, might induce an imbalance between cell death and proliferation inducing a paradoxical increase of CNS tumor necrosis factor (TNF), affecting the activity of lymphocytes, microglia and macrophages, triggering aberrant inflammation and demyelination. Immune checkpoint inhibitors are a new class of antineoplastic drugs that enhance the immune response against tumor cells by an upregulation of T-cell activity. However, this hyperactivation of the immune system might be associated with induction of unwanted autoimmune responses. In this paper we review the risk factors, the possible pathological mechanisms and the magnetic resonance imaging (MRI) findings of these drug-related demyelinating syndromes., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Pediatric arterial ischemic stroke (AIS), which was thought to be a rare disorder, is being increasingly recognized as an important cause of neurological morbidity, thanks to new advances in neuroimaging., Objective: The aim of this study was to review the main etiologies of stroke due to arteriopathy in children., Methods: Using a series of cases from our institution, we addressed its epidemiological aspects, physiopathology, imaging findings from CT, MR angiography, MR conventional sequences and MR DWI, and nuclear medicine findings., Results: Through discussion of the most recent classification for childhood AIS (Childhood AIS Standardized Classification and Diagnostic Evaluation, CASCADE), we propose a modified classification based on the anatomical site of disease, which includes vasculitis, varicella, arterial dissection, moyamoya, fibromuscular dysplasia, Takayasu's arteritis and genetic causes (such as ACTA-2 mutation, PHACE syndrome and ADA-2 deficiency). We have detailed each of these separately. Conclusions: Prompt recognition of AIS and thorough investigation for potential risk factors are crucial for a better outcome. In this scenario, neurovascular imaging plays an important role in diagnosing AIS and identifying children at high risk of recurrent stroke.

When it is necessary to evaluate dental structures, the typical method is to obtain intraoral or panoramic X-rays at specialized dental clinics. However, in the daily practice of head and neck radiology, or even general radiology, it is common to encounter clinical situations or examination findings related to dental problems that should not be ignored. Because such problems can often be responsible for the clinical complaints of patients, this review aims to assist radiologists in identifying and describing common dental conditions on computed tomography of paranasal sinuses, face, and neck. It is important for radiologists to have knowledge of dental arch anatomy and its relationships with facial structures, as well as of major dental pathologies, including periapical sclerotic lesions, odontogenic cysts, fistulas, and abscesses, together with knowledge of incidental findings without clinical repercussions, which should be easily identified and stressed by the radiologist when necessary. The imaging methods most commonly used in evaluation of paranasal sinuses and face are computed tomography and magnetic resonance imaging. Those methods allow radiologists to recognize and become familiar with the main dental findings. The description of such findings by a radiologist can lead to a change in treatment strategy.

Changes in hippocampal subfield volumes (HSV) along the Alzheimer's disease (AD) continuum have been scarcely investigated to date in elderly subjects classified based on the presence of β-amyloid aggregation and signs of neurodegeneration. We classified patients (either sex) with mild dementia compatible with AD (n = 35) or amnestic mild cognitive impairment (n = 39), and cognitively unimpaired subjects (either sex; n = 26) using [ 11 C]PIB-PET to assess β-amyloid aggregation (A+) and [ 18 F]FDG-PET to account for neurodegeneration ((N)+). Magnetic resonance imaging-based automated methods were used for HSV and white matter hyperintensity (WMH) measurements. Significant HSV reductions were found in A+(N)+ subjects in the presubiculum/subiculum complex and molecular layer, related to worse memory performance. In both the A+(N)+ and A+(N)- categories, subicular volumes were inversely correlated with the degree of Aβ deposition. The A-(N)+ subgroup showed reduced HSV relative to the A-(N)- subgroup also in the subiculum/presubiculum. Combining all (N)- subjects, HSV were lower in subjects presenting significant cognitive decline irrespective of A+/A- classification (controlling for WMH load); these between-group differences were detected again in the presubiculum, but also involved the CA4 and granular layer. These findings demonstrate that differential HSV reductions are detectable both in (N)+ and (N)- categories along the AD continuum, and are directly related to the severity of cognitive deficits. HSV reductions are larger both in A+(N)+ and A+(N)- subjects in direct proportion to the degree of Aβ deposition. The meaningful HSV reductions detected in the A-(N)+ subgroup highlights the strength of biomarker-based classifications outside of the classical AD continuum., (© 2020 Wiley Periodicals LLC.)

The objective of this article is to share the strategy we used in order to restructure the radiology and diagnostic imaging department of a referral institution during the coronavirus disease 2019 pandemic, on the basis of the current recommendations. It is essential to integrate the work of supervisors, preceptors, and residents, maintaining communication and sharing decisions, with mutual support, as well as to determine the best strategy to be adopted in this scenario of uncertainty and constant change, while also ensuring adequate emotional support for all parties.

Background: Repetitive peripheral nerve sensory stimulation (RPSS) has emerged as a potential adjuvant strategy to motor training in stroke rehabilitation. The aim of this study is to test the hypothesis that 3 h sessions of active RPSS associated with functional electrical stimulation (FES) and task-specific training (TST) distributed three times a week, over 6 weeks, is more beneficial to improve upper limb motor function than sham RPSS in addition to FES and TST, in subjects with moderate to severe hand motor impairments in the chronic phase (>6 months) after stroke. Methods: In this single-center, randomized, placebo controlled, parallel-group, double-blind study we compare the effects of 18 sessions of active and sham RPSS as add-on interventions to FES and task-specific training of the paretic upper limb, in 40 subjects in the chronic phase after ischemic or hemorrhagic stroke, with Fugl-Meyer upper limb scores ranging from 7 to 50 and able to voluntarily activate any active range of wrist extension. The primary outcome measure is the Wolf Motor Function Test (WMFT) after 6 weeks of treatment. The secondary outcomes are the WMFT at 3, 10, and 18 weeks after beginning of treatment, as well as the following outcomes measured at 3, 6, 10, and 18 weeks: Motor Activity Log; active range of motion of wrist extension and flexion; grasp and pinch strength in the paretic and non-paretic sides (the order of testing is randomized within and across subjects); Modified Ashworth Scale; Fugl-Meyer Assessment-Upper Limb in the paretic arm; Barthel Index; Stroke Impact Scale. Discussion: This project represents a major step in developing a rehabilitation strategy with potential to have impact on the treatment of stroke patients with poor motor recovery in developing countries worldwide. The study preliminarily evaluates a straightforward, non-invasive, inexpensive intervention. If feasibility and preliminary efficacy are demonstrated, further investigations of the proposed intervention (underlying mechanisms/ effects in larger numbers of patients) should be performed. Trial Registration: NCT02658578., (Copyright © 2020 Conforto, Machado, Menezes, Ribeiro, Luccas, Pires, Leite, Plow and Cohen.)

Objective: To assess the accuracy of magnetic resonance imaging (MRI) for the diagnosis of hallux valgus using radiography during weight bearing as the gold standard., Materials and Methods: This was a retrospective analysis of all patients undergoing MRI of the foot and radiography of the foot during weight bearing at our institution between January and June of 2015. The hallux valgus angle (HVA) was measured on MRI and radiography. The Wilcoxon signed-rank test and simple linear regression were used in order to compare measurements. Patients were divided into two groups according to the HVA determined on radiography: > 15° (hallux valgus) and ≤ 15° (control). Qualitative and quantitative assessments of MRI scans were performed. For quantitative assessment, receiver operating characteristic curves were used in order to determine the HVA cutoff with the highest accuracy., Results: A total of 66 MRI scans were included, 22 in the hallux valgus group and 44 in the control group. Wilcoxon signed-rank tests indicated a significant difference between the radiography and MRI measurements. Simple linear regression showed a nonlinear relationship between the measurements and values did not present a strong correlation. In comparison with the radiography measurements, MRI with an HVA cutoff of 16.4° exhibited the highest accuracy (86%). The accuracy of the subjective (qualitative) assessment was inferior to the objective assessment (measurement of the HVA)., Conclusion: Hallux valgus can be diagnosed by measuring the HVA on MRI, satisfactory accuracy being achieved with an HVA cutoff of 16.4°.

Toxic and metabolic brain disorders are relatively uncommon diseases that affect the central nervous system, but they are important to recognize as they can lead to catastrophic outcomes if not rapidly and properly managed. Imaging plays a key role in determining the most probable diagnosis, pointing to the next steps of investigation, and providing prognostic information. The majority of cases demonstrate bilateral and symmetric involvement of structures at imaging, affecting the deep gray nuclei, cortical gray matter, and/or periventricular white matter, and some cases show specific imaging manifestations. When an appropriate clinical situation suggests exogenous or endogenous toxic effects, the associated imaging pattern usually indicates a restricted group of diagnostic possibilities. Nonetheless, toxic and metabolic brain disorders in the literature are usually approached in the literature by starting with common causal agents and then reaching imaging abnormalities, frequently mixing many different possible manifestations. Conversely, this article proposes a systematic approach to address this group of diseases based on the most important imaging patterns encountered in clinical practice. Each pattern is suggestive of a most likely differential diagnosis, which more closely resembles real-world scenarios faced by radiologists. Basic pathophysiologic concepts regarding cerebral edemas and their relation to imaging are introduced-an important topic for overall understanding. The most important imaging patterns are presented, and the main differential diagnosis for each pattern is discussed. Online supplemental material is available for this article. © RSNA, 2019.

Objectives: To evaluate the diagnostic performance and interobserver agreement of PI-RADS v2., Materials and Methods: In this Institutional Review Board approved single-center retrospective study, 98 patients with clinically suspected PCa who underwent 3-T multiparametric MRI followed by MRI/TRUS fusion-guided prostate biopsy were included from June 2013 to February 2015. Two radiologists (R1 and R2) with 8 and 1 years of experience in abdominal radiology reviewed the MRI scans and assigned PI-RADS v2 scores in all prostate zones. PI-RADS v2 were compared to MRI/TRUS fusion-guided biopsy results, which were classified as negative, PCa, and significant PCa (sPCa)., Results: Sensitivity, specificity, NPV, PPV and accuracy for PCa was 85.7% (same for all metrics) for R1 and 81.6%, 79.6%, 81.2%, 80.0% and 80.6% for R2. For detecting sPCa, the corresponding values were 95.3%, 85.4%, 95.9%, 83.7% and 89.8% for R1 and 93.0%, 81.8%, 93.7%, 86.7% and 86.7% for R2. There was substantial interobserver agreement in assigning PI-RADS v2 score as negative (1, 2, 3) or positive (4, 5) (Kappa=0.78). On multivariate analysis, PI-RADS v2 (p <0.001) was the only independent predictor of sPCa compared with age, abnormal DRE, prostate volume, PSA and PSA density., Conclusions: Our study population demonstrated that PI-RADS v2 had high diagnostic accuracy, substantial interobserver agreement, and it was the only independent predictor of sPCa., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Stroke is a leading cause of disability worldwide. Motor impairments occur in most of the patients with stroke in the acute phase and contribute substantially to disability. Diffusion tensor imaging (DTI) biomarkers such as fractional anisotropy (FA) measured at an early phase after stroke have emerged as potential predictors of motor recovery. In this narrative review, we: (1) review key concepts of diffusion MRI (dMRI); (2) present an overview of state-of-art methodological aspects of data collection, analysis and reporting; and (3) critically review challenges of DTI in stroke as well as results of studies that investigated the correlation between DTI metrics within the corticospinal tract and motor outcomes at different stages after stroke. We reviewed studies published between January, 2008 and December, 2018, that reported correlations between DTI metrics collected within the first 24 h (hyperacute), 2-7 days (acute), and >7-90 days (early subacute) after stroke. Nineteen studies were included. Our review shows that there is no consensus about gold standards for DTI data collection or processing. We found great methodological differences across studies that evaluated DTI metrics within the corticospinal tract. Despite heterogeneity in stroke lesions and analysis approaches, the majority of studies reported significant correlations between DTI biomarkers and motor impairments. It remains to be determined whether DTI results could enhance the predictive value of motor disability models based on clinical and neurophysiological variables.

Background: Post-stroke depression (PSD) and cognitive impairment (PCI) are common conditions. This study aims to describe the protocol and preliminary findings of an investigation into factors associated with PSD and PCI 1-3 months after stroke (subacute phase) in survivors from the Study of Stroke Mortality and Morbidity (EMMA study)., Methods: Stroke patients underwent to clinical and neurological evaluations on admission to hospital. Cerebral magnetic resonance and biomarkers (serotonin, BDNF, IL-6 and IL-18) were carried out in the subacute phase. DSM-IV major depression for the diagnosis of PSD, cognitive functioning for the diagnosis of PCI and functional disability were also recorded at same time., Results: Of the 103 eligible patients, 85.4% had ischemic stroke and 73.7% had first-ever stroke. In the subacute phase, 27.2% had PCI and 13.6% had current PSD (5.8% with 'first episode' and 7.8% with 'recurrent' depression). PCI was associated with low education (0-7 years of formal education: 75%) and ageing (median age: 70; interquartile range: 59-75 y-old). Left-sided stroke was more frequently associated with increased PCI than right-sided stroke (71.4% vs. 28.4%, p = 0.005). PSD was neither associated with stroke laterality nor tentorial area. Overall, biomarkers levels were not alterated in patients with PSD and PCI., Limitations: Findings are based on small sample and less disabled stroke participants, e.g. those without aphasia and deafness., Conclusions: Findings reinforce the need of early recognition and rehabilitation of PCI and PSD, mainly among those less educated and with left-sided stroke. PSD might occur through a pathophysiological pathway other than classical depression., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Low-education attainment is associated with worse cognitive performance in multiple sclerosis (MS) patients, and possibly with a lower cognitive reserve and/or increased inflammatory activity. Cognitive reserve refers to the capability of a source of intellectual enrichment in attenuating a negative effect of a disease-related factor; while the inflammatory activity is often related to T2-lesion load (T2-LL) increase., Objective: To disentangle the effects of cognitive reserve and an increased T2-LL in MS-patients with low-education levels., Methods: The study included 136 MS patients and 65 healthy-controls, divided in low-education (12 years or less of school education without obtaining any technical superior degree) and high-education (more than 12 years of school education with technical or superior degree) groups. An extensive battery of neuropsychological tests was applied examining intelligence quotient and six cognitive domains. Test results were z-scored and subjects with z-scores ≤ -1.5 in two or more domains were considered cognitively impaired. To test the factors associated with worse cognitive performance, regression models were applied using average cognition as target; education level, Expanded Disability Status Scale (EDSS), T2-LL, disease duration, age of disease onset, age and gender as predictors. We also tested the correlation between T2-LL and cognition in the groups. To investigate the role of education level as a source of intellectual enrichment/cognitive reserve in different stages of MS, we sub-divided the MS patients in three groups according to the disease duration (less than 5 years, between 5 and 10 years and more than 10 years)., Results: Worse average cognition was associated with low-education level, higher T2-LL and male gender. A higher frequency of cognitively impaired patients was observed in MS patients with low-education level, in all stages of the disease. In patients with a disease duration shorter than five years, there was a lower correlation between worse average cognition and T2-LL in the high-education level group, compared to the patients with low-education level; in MS patients with longer disease duration, we observed a stronger correlation between lesion burden and cognitive impairment in both groups., Conclusion: Education attainment is a source of intellectual enrichment and can enhance the cognitive reserve in MS patients. The protective effect of a high-education level was stronger in patients with less than five years of disease, suggesting a stronger role of cognitive reserve in short-term disease. In long-term disease we observed a greater impact of increased inflammatory activity on cognition., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: A 4.5-year follow-up study was conducted to characterize baseline verbal episodic memory (VEM) and its behavior and to assess the effects of relapsing-remitting multiple sclerosis (RRMS) on this domain., Methods: Twenty-nine patients with RRMS underwent two neuropsychological assessments performed an average of 4.5 years apart. Twenty-six control participants underwent a single neuropsychological assessment. A significance level of p < 0.005 was adopted to denote a significant difference between the groups on the Mann Whitney and Wilcoxon paired statistical analyses., Results: No statistical difference was found in the results of the VEM tests between the first and second neuropsychological assessments of the patients. However, a statistical difference was evident between the patient and control groups in the results of the VEM tests., Conclusion: The patient group showed changes in the VEM relative to the control group. After approximately 4.5 years of disease, the patient performance on the VEM stabilized or improved.

Traumatic brain injury (TBI) is the number one cause of death and morbidity among young adults. Moreover, survivors are frequently left with functional disabilities during the most productive years of their lives. One main aspect of TBI pathology is diffuse axonal injury, which is increasingly recognized due to its presence in 40% to 50% of all cases that require hospital admission. Diffuse axonal injury is defined as widespread axonal damage and is characterized by complete axotomy and secondary reactions due to overall axonopathy. These changes can be seen in neuroimaging studies as hemorrhagic focal areas and diffuse edema. However, the diffuse axonal injury findings are frequently under-recognized in conventional neuroimaging studies. In such scenarios, diffuse tensor imaging (DTI) plays an important role because it provides further information on white matter integrity that is not obtained with standard magnetic resonance imaging sequences. Extensive reviews concerning the physics of DTI and its use in the context of TBI patients have been published, but these issues are still hazy for many allied-health professionals. Herein, we aim to review the current contribution of diverse state-of-the-art DTI analytical methods to the understanding of diffuse axonal injury pathophysiology and prognosis, to serve as a quick reference for those interested in planning new studies and who are involved in the care of TBI victims. For this purpose, a comprehensive search in Pubmed was performed using the following keywords: "traumatic brain injury", "diffuse axonal injury", and "diffusion tensor imaging".

A large number of gadolinium chelates have recently been tested in clinical trials. Some of those have already been approved for clinical use in the United States and Europe. Thus, new diagnostic perspectives have been incorporated into magnetic resonance imaging studies. Among such gadolinium chelates are hepatobiliary-specific contrast agents (HSCAs), which, due to their property of being selectively taken up by hepatocytes and excreted by the biliary ducts, have been widely used for the detection and characterization of focal hepatic lesions. In comparison with conventional magnetic resonance cholangiography (MRC), HSCA-enhanced MRC provides additional information, with higher spatial resolution and better anatomic evaluation of a non-dilated biliary tree. A thorough anatomic assessment of the biliary tree is crucial in various hepatic surgical procedures, such as complex resection in patients with colorectal cancer and living-donor liver transplantation. However, the use of HSCA-enhanced MRC is still limited, because of a lack of data in the literature and the poor familiarity of radiologists regarding its main indications. This pictorial essay aims to demonstrate the use of HSCA-enhanced MRC, with particular emphasis on anatomical analysis of the biliary tree, clinical applications, and the most important imaging findings.

In recent years, small vessel disease (SVD) has been recognized for its major impact on cognitive impairment in elderly people, where it is often difficult to separate its effects from those of neurodegenerative diseases individually. SVD is a systemic disease, probably related to diffuse endothelial dysfunction, which affects the perforating arterioles, capillaries and venules in the brain. Although often asymptomatic, it is responsible for almost half of all dementia cases and a significant proportion of stroke cases. Imaging features found on magnetic resonance include recent small subcortical infarctions, lacunes of presumed vascular origin, white matter hyperintensity of presumed vascular origin, prominent perivascular spaces and cerebral microbleeds. The recognition of these imaging findings as a spectrum of the same disease caused by endothelial dysfunction of small cerebral vessels can allow an overall analysis of the disease and thus the development of more effective preventive and therapeutic strategies., Competing Interests: Disclosure: The authors report no conflicts of interest.

Objective: Juvenile myoclonic epilepsy (JME) is a subtype of genetically determined generalized epilepsy that does not present abnormalities on conventional magnetic resonance imaging. The aim of this study was to identify metabolic alterations in the thalamus in a clinically homogeneous sample of patients with easy-to-control JME, using short-echo time proton magnetic resonance spectroscopy (MRS)., Materials and Methods: We performed single-voxel (2 cm × 2 cm × 2 cm), short-echo time (TE = 35 ms) proton MRS of the thalamus in 21 patients with JME and in 14 healthy age-matched controls. We quantified N-acetylaspartate (NAA), total NAA, creatine (Cr), choline, and myo-inositol (MI), as well as the sum of glutamate and glutamine signals, all scaled to internal water content, and we calculated metabolite ratios using Cr as a reference. Values of p < 0.05 were considered significant., Results: The MI level and the MI/Cr ratio were significantly lower in the thalami of patients diagnosed with JME than in those of the controls. Other metabolites and their ratios did not differ significantly between the two groups., Conclusion: In our sample of 21 JME patients, we identified lower levels of MI in the thalamus. No significant abnormalities were observed in the concentrations or ratios of other metabolites.

Creatine/phosphorylcreatine (PCr) responses to creatine supplementation may be modulated by age, diet, and tissue, but studies assessing this possibility are lacking. Therefore we aimed to determine whether PCr responses vary as a function of age, diet, and tissue. Fifteen children, 17 omnivorous and 14 vegetarian adults, and 18 elderly individuals ("elderly") participated in this study. Participants were given placebo and subsequently creatine (0.3 g·kg -1 ·day -1 ) for 7 days in a single-blind fashion. PCr was measured through phosphorus magnetic resonance spectroscopy ( 31 P-MRS) in muscle and brain. Creatine supplementation increased muscle PCr in children ( P < 0.0003) and elderly ( P < 0.001), whereas the increase in omnivores did not reach statistically significant difference ( P = 0.3348). Elderly had greater PCr increases than children and omnivores ( P < 0.0001 for both), whereas children experienced greater PCr increases than omnivores ( P = 0.0022). In relation to diet, vegetarians ( P < 0.0001), but not omnivores, had significant increases in muscle PCr content. Brain PCr content was not affected by creatine supplementation in any group, and delta changes in brain PCr (-0.7 to +3.9%) were inferior to those in muscle PCr content (+10.3 to +27.6%; P < 0.0001 for all comparisons). PCr responses to a standardized creatine protocol (0.3 g·kg -1 ·day -1 for 7 days) may be affected by age, diet, and tissue. Whereas creatine supplementation was able to increase muscle PCr in all groups, although to different extents, brain PCr was shown to be unresponsive overall. These findings demonstrate the need to tailor creatine protocols to optimize creatine/PCr accumulation both in muscle and in brain, enabling a better appreciation of the pleiotropic properties of creatine. NEW & NOTEWORTHY A standardized creatine supplementation protocol (0.3 g·kg -1 ·day -1 for 7 days) effectively increased muscle, but not brain, phosphorylcreatine. Older participants responded better than younger participants whereas vegetarians responded better than omnivores. Responses to supplementation are thus dependent on age, tissue, and diet. This suggests that a single "universal" protocol, originally designed for increasing muscle creatine in young individuals, may lead to heterogeneous muscle responses in different populations or even no responses in tissues other than skeletal muscle., (Copyright © 2017 the American Physiological Society.)

A 77 year-old men developed a subacute-onset, rapidly progressive cognitive decline. After 6 months of evolution, he scored 6 on the Mini-Mental State Examination and had left hemiparesis and hemineglect. The patient died 11 months after the onset of cognitive symptoms. Brain MRI showed microhemorrhages on gradient-echo sequence and confluent areas of white matter hyperintensities on T2-weighted images. Brain biopsy revealed amyloid-β peptide deposition in vessel walls, some of them surrounded by micro-bleeds. In this case report, we discuss the role of cerebral amyloid angiopathy (CAA) in cognitive decline, due to structural lesions associated with hemorrhages and infarcts, white matter lesions and co-morbidity of Alzheimer's disease, as well as the most recently described amyloid angiopathy-related inflammation., Competing Interests: Disclosure: The authors report no conflicts of interest.

To compare metabolite ratios in the posterior cingulate with the Mini-Mental State Examination (MMSE) test scores in patients with mild or moderate Alzheimer disease and in controls., Methods: We evaluated 29 patients with mild or moderate Alzheimer disease and 15 controls by proton spectroscopy with the voxel located in the posterior cingulate. The MMSE was applied to all patients and controls. The metabolic ratios: N-acetyl-aspartate/creatine (Naa/Cr), mio-inositol/creatine (mI/Cr) and mio-inositol/N-acetyl-aspartate (mI/Naa) were obtained and then post-processed using the MRUI software (magnetic resonance user interface)., Results: Correlation between Naa/Cr and mI/Naa ratios in the posterior cingulate with the MMSE was observed, and a positive correlation with Naa/Cr and negative correlation with mI/Naa were seen. The mI/r ratio presented no correlation with MMSE scores., Conclusion: The positive correlation with Naa/Cr, and negative correlation with mI/Naa may corroborate that neuronal density/viability is associated to a higher MMSE score.