Proton spectroscopy study of the masseter in patients with systemic sclerosis

OBJECTIVE: To evaluate metabolite concentration in the masseter of patients with systemic sclerosis, by analyzing creatine, choline, lipid and lactate levels, and correlating them with the presence of mandibular osteolysis. MATERIALS AND METHODS: The sample included 25 individuals, 15 of them with diagnosis of systemic sclerosis, divided into two groups according to the presence (group I) or absence (group II) of osteolysis, and 10 healthy individuals (group III, control). All of them were submitted to proton magnetic resonance spectroscopy with PRESS sequence and 3D acquisition. RESULTS: Metabolite analysis showed that the creatine and lipid levels were the same for the three groups. Patients in group I presented higher levels of choline when compared with group III. On the other hand, lower lactate levels were observed in groups I and II when compared with the healthy individuals. Creatine/lipid and choline/lactate ratios were the same in the three groups. CONCLUSION: Lower lactate levels were observed in the patients with systemic sclerosis (groups I and II). Choline levels were increased in the patients with mandibular osteolysis (group I). Creatine/choline, lipid/lactate and choline/lipid ratios were different among the three groups. Further studies are necessary to understand the role played by the masseter in the development of mandibular osteolysis.OBJETIVO: Avaliar a concentração de metabólitos no masseter em portadores de esclerose sistêmica, analisando os índices de creatina, colina, lipídio e lactato, e relacionar com a presença de osteólise mandibular. MATERIAIS E MÉTODOS: Foram selecionados 25 pacientes, sendo 15 com diagnóstico de esclerose sistêmica e agrupados de acordo com a presença (grupo I) ou ausência (grupo II) de osteólise, e 10 indivíduos normais (grupo III, controle). Todos foram submetidos a exame de espectroscopia de próton por ressonância magnética, com técnica PRESS e aquisição tridimensional. RESULTADOS: O estudo dos metabólitos dos três grupos apresentou os mesmos valores absolutos de creatina e lipídio. Os pacientes do grupo I apresentaram maior quantidade de colina em relação aos do grupo III. Já os indivíduos dos grupos I e II apresentaram menor quantidade de lactato em relação aos indivíduos normais. Os índices creatina/lipídio e colina/lactato foram os mesmos em todos os grupos. CONCLUSÃO: Observamos menor quantidade de lactato nos pacientes com esclerose sistêmica (grupos I e II). A colina está aumentada nos pacientes com osteólise mandibular (grupo I). Os índices creatina/colina, creatina/lactato, lipídio/lactato e colina/lipídio foram diferentes entre os grupos estudados. Mais estudos são necessários para a compreensão da participação do masseter no desenvolvimento da osteólise mandibular.Hospital Heliópolis Serviço de Estomatologia e Cirurgia Buco Maxilo FaciaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnóstico por ImagemUNIFESP, EPM, Depto. de Diagnóstico por ImagemSciEL

Germinoma involving the basal ganglia and thalamus with brain stem invasion: case report

We report an unusual case of germinoma arising from the basal ganglia and thalamus with brain stem invasion, with emphasis on computed tomography and magnetic resonance findings. Diagnosis was confirmed by histopathologic examination. Early detection of this tumor is important due to its potential response to treatment.Descrevemos o caso de um paciente com diagnóstico de germinoma nos núcleos da base e tálamo, com invasão do tronco cerebral, ressaltando as características observadas nos exames de tomografia computadorizada e de ressonância magnética, os possíveis diagnósticos diferenciais, e a necessidade da comprovação anátomo-patológica, por tratar-se de localização pouco frequente de um tumor com possibilidade de evolução favorável após tratamento com quimio e radioterapia.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Ataxia espástica autossômica recessiva de Charlevoix-Saguenay (ARSACS): aspectos clínicos e de neuroimagem típicos em uma família brasileira

Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is a neurodegenerative disorder characterized by late-infantile onset spastic ataxia and other neurological features. ARSACS has a high prevalence in northeastern Quebec, Canada. Several ARSACS cases have been reported outside Canada in recent decades. This is the first report of typical clinical and neuroimaging features in a Brazilian family with probable diagnosis of ARSACS.A ataxia espástica autossômica recessiva de Charlevoix-Saguenay (ARSACS) é doença degenerativa do sistema nervoso, caracterizada por ataxia associada a espasticidade, entre outras manifestações neurológicas, de início na infância. A doença tem alta prevalência na região de Quebec, no Canadá. Muitos relatos de ARSACS têm sido descritos fora do Canadá nas últimas décadas. Nesse artigo, relatamos a primeira descrição dos aspectos clínicos e de neuroimagem típicos em uma família brasileira com provável diagnóstico de ARSACS.Universidade Federal de São Paulo (UNIFESP) Division of General Neurology and Ataxias Department of Neurology and NeurosurgeryUniversidade Federal de São Paulo (UNIFESP) Departament of Diagnostic ImagingUNIFESP, Division of General Neurology and Ataxias Department of Neurology and NeurosurgeryUNIFESP, Departament of Diagnostic ImagingSciEL

Magnetic resonance imaging in the differential diagnosis of infectious and inflammatory conus medullaris lesions

The conus medullaris is frequently affected by inflammatory and infectious lesions which many times are hardly differentiated because of the similarity of their clinical history and physical examination among the different etiologies. Magnetic resonance imaging presents high sensitivity in the detection of these lesions and plays a relevant role in the diagnosis as well as in the evolutive control of the condition. The present pictorial essay with selected cases from the archives of the authors' institution is aimed at demonstrating imaging findings which might help in the diagnosis of a specific etiology amongst inflammatory an infectious conditions and in the differentiation with diseases of neoplastic and vascular etiologies, for example. Findings such as enhancement pattern, presence of cysts, edema and involvement of other regions of the central nervous system are important for this differentiation, and may define a specific etiology as associated with clinical and laboratory tests findings.O cone medular é frequentemente acometido por lesões de etiologia inflamatória e infecciosa, muitas vezes de difícil diferenciação devido a história clínica e exame físico semelhantes entre as diversas entidades. A ressonância magnética apresenta alta sensibilidade na detecção de lesões no cone medular e tem importante papel no diagnóstico e controle evolutivo. Este ensaio iconográfico com casos selecionados dos arquivos do nosso serviço tem como objetivo demonstrar achados de imagem que possam auxiliar no diagnóstico de uma etiologia específica entre as doenças inflamatórias e infecciosas e na diferenciação com doenças de outras etiologias como neoplasias e causas vasculares. Características como padrão de realce, presença de cistos, edema, além do acometimento de outras regiões do sistema nervoso central são importantes para esta diferenciação, podendo definir uma etiologia específica quando associadas ao quadro clínico e laboratorial.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnóstico por ImagemUNIFESP, EPM, Depto. de Diagnóstico por ImagemSciEL

Magnetic resonance spectroscopy imaging in the diagnosis of prostate cancer: initial experience

OBJECTIVE: To report an experiment involving the introduction of a protocol utilizing commercially available three-dimensional 1H magnetic resonance spectroscopy imaging (3D 1H MRSI) method in patients diagnosed with prostatic tumors under suspicion of neoplasm. MATERIALS AND METHODS: Forty-one patients in the age range between 51 and 80 years (mean, 67 years) were prospectively evaluated. The patients were divided into two groups: patients with one or more biopsies negative for cancer and high specific-prostatic antigen levels (group A), and patients with cancer confirmed by biopsy (group B). The determination of the target-area (group A) or the known cancer extent (group B) was based on magnetic resonance imaging and MRSI studies. RESULTS: The specificity of MRSI in the diagnosis of prostate cancer was lower than the specificity reported in the literature (about 47%). On the other hand, for tumor staging, it corresponded to the specificity reported in the literature. CONCLUSION: The introduction and standardization of 3D 1H MRSI has allowed the obtention of a presumable diagnosis of prostate cancer, by a combined analysis of magnetic resonance imaging and metabolic data from 3D 1H MRSI.OBJETIVO: Demonstrar a experiência na implantação de um protocolo de espectroscopia por ressonância magnética do 1H tridimensional (3D 1H MRSI), disponível comercialmente, aplicando-o em pacientes com suspeita de neoplasia prostática e com diagnóstico estabelecido de tumor prostático. MATERIAIS E MÉTODOS: Estudo realizado de forma prospectiva, em 41 pacientes com idades entre 51 e 80 anos (média de 67 anos). Dois grupos foram formados: pacientes com uma ou mais biópsias negativas para câncer e antígeno prostático específico elevado (grupo A) e pacientes com câncer confirmado por biópsia (grupo B). Procurou-se, a partir dos resultados da ressonância magnética e espectroscopia por ressonância magnética, determinar a área-alvo (grupo A) ou a extensão do câncer conhecido (grupo B). RESULTADOS: No diagnóstico de câncer de próstata a espectroscopia por ressonância magnética apresentou especificidade abaixo da descrita pela literatura, cerca de 47%. Já para o estadiamento do tumor diagnosticado, houve correspondência com a literatura. CONCLUSÃO: A implantação e padronização da espectroscopia por ressonância magnética permitiram a obtenção de informações importantes para o diagnóstico presuntivo da existência de câncer de próstata, combinando as imagens por ressonância magnética com os dados metabólicos da espectroscopia por ressonância magnética.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnóstico por ImagemUniversidade Federal do AmazonasUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Hospital São PauloUNIFESP, EPM, Depto. de Diagnóstico por ImagemUNIFESP, EPM, Hospital São PauloSciEL

Anormalidade de sinal na imagem por RM do pólo temporal na epilepsia do lobo temporal com esclerose hipocampal: um estudo pela seqüência inversão recuperação com supressão da água livre (FLAIR)

OBJECTIVE: To determine the frequency and regional involvement of temporal pole signal abnormality (TPA) in patients with hippocampal sclerosis (HS) using fluid-attenuated inversion-recovery (FLAIR) MR imaging, and to correlate this feature with history. METHOD: Coronal FLAIR images of the temporal pole were assessed in 120 patients with HS and in 30 normal subjects, to evaluate gray-white matter demarcation. RESULTS: Ninety (75%) of 120 patients had associated TPA. The HS side made difference regarding the presence of TPA, with a left side prevalence (p=0.04, chi2 test). The anteromedial zone of temporal pole was affected in 27 (30%) out of 90 patients. In 63 (70%) patients the lateral zone were also affected. Patients with TPA were younger at seizure onset (p=0.018), but without association with duration of epilepsy. CONCLUSION: Our FLAIR study show temporal pole signal abnormality in 3/4 of patients with HS, mainly seen on the anteromedial region, with a larger prevalence when the left hippocampus was involved.OBJETIVO: Determinar a freqüência e o envolvimento regional da anormalidade de sinal do pólo temporal (APT) em pacientes com esclerose hipocampal (EH) utilizando seqüência inversão recuperação com supressão da água (FLAIR) por RM, e correlacioná-la com a história. MÉTODO: Foram analisadas as imagens coronais FLAIR dos pólos temporais de 120 pacientes com EH e de 30 indivíduos normais, para avaliar a demarcação entre substâncias branca e cinzenta. RESULTADOS: Noventa (75%) dos 120 pacientes tinham APT associada. Houve prevalência do lado esquerdo (p=0.04, chi2 teste) na relação entre APT e o lado da EH. A zona ântero-medial estava acometida em 27 (30%) destes pacientes. Em 63 (70%) pacientes também a zona lateral estava acometida. Pacientes com APT apresentaram início da epilepsia quando mais jovens (p=0.018), porém sem associação com a sua duração. CONCLUSÃO: A seqüência FLAIR mostra haver ATP em 3/4 dos pacientes com EH, principalmente na região ântero-medial, com maior prevalência quando o hipocampo esquerdo estava envolvido.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Diagnóstico por ImagemUNIFESP-EPM Departamento de Diagnóstico por ImagemUNIFESP-EPM Departamento de Neurologia e NeurocirurgiaUNIFESP, EPM, Depto. de Diagnóstico por ImagemUNIFESP, EPM Depto. de Diagnóstico por ImagemUNIFESP, EPM Depto. de Neurologia e NeurocirurgiaSciEL

Multiple gliomas: four different presentations

Multiple gliomas are uncommon and may be classified according to: a) the time of presentation in early (at diagnosis) or late (during treatment); b) the characteristics of computed tomography or magnetic resonance imaging (CT/MRI) in multifocal (with evidence of spread) and multicentric (without evidence of spread). From 212 patients with histopathologic diagnosis of glioma evaluated from March/90 to September/99, 15 (7%) had multiple lesions. We describe 4 patients: early multicentric, late multicentric, early multifocal and late multifocal, with emphasis on characteristics of CT/MRI and possible differential diagnosis. The differential diagnosis of multiple lesions in the central nervous system includes mainly infectious/inflammatory diseases and metastasis, however multiple gliomas should always be considered, even in patients with known systemic cancer, as described by others. Considering that CT/MRI features are not definite, the diagnosis should always be confirmed by histopathologic examination.Os gliomas múltiplos são relativamente raros e podem ser classificados didaticamente de acordo com: a) a época da apresentação, em precoces (quando presentes desde o diagnóstico inicial) ou tardios (quando presentes durante a evolução); e b) as características dos exames de imagem, em multifocais (quando há evidência de contiguidade das lesões) ou multicêntricos (quando não é possível identificar contiguidade das lesões). Entre os 212 pacientes com diagnóstico anatomopatológico de glioma, acompanhados prospectivamente no setor de neuro-oncologia de março/90 a setembro/99, 15 (7%) apresentaram lesões múltiplas. Descrevemos 4 casos característicos de cada uma das possíveis apresentações: multicêntrico precoce, multicêntrico tardio, multifocal precoce e multifocal tardio, com ênfase nas características de imagem e possíveis diagnósticos diferenciais. O diagnóstico diferencial das lesões múltiplas no sistema nervoso central inclui doenças inflamatórias e infecciosas, além de metástases. A possibilidade de tratar-se de tumores de origem glial, entretanto, deve ser sempre lembrada, mesmo naqueles pacientes com diagnóstico de neoplasia sistêmica conhecida, conforme já descrito na literatura. O diagnóstico histológico se impõe, uma vez que as características de imagem não permitem diagnóstico de certeza.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Diffusion-weighted imaging with color-coded images: towards a reduction in reading time while keeping a similar accuracy

The aim of this study was to develop a diagnostic tool capable of providing diffusion and apparent diffusion coefficient (ADC) map information in a single color-coded image and to assess the performance of color-coded images compared with their corresponding diffusion and ADC map. The institutional review board approved this retrospective study, which sequentially enrolled 36 head MRI scans. Diffusion-weighted images (DWI) and ADC maps were compared to their corresponding color-coded images. Four raters had their interobserver agreement measured for both conventional (DWI) and color-coded images. Differences between conventional and color-coded images were also estimated for each of the 4 raters. Cohen's kappa and percent agreement were used. Also, paired-samples t-test was used to compare reading time for rater 1. Conventional and color-coded images had substantial or almost perfect agreement for all raters. Mean reading time of rater 1 was 47.4 seconds for DWI and 27.9 seconds for color-coded images (P = .00007). These findings are important because they support the role of color-coded images as being equivalent to that of the conventional DWI in terms of diagnostic capability. Reduction in reading time (which makes the reading easier) is also demonstrated for one rater in this study.Departamento de Diagnóstico por Imagem da Escola Paulista de Medicina da UNIFESP, Rua Napoleão de Barros, 800 Vila Clementino, 04024-002 São Paulo, SP, BrazilDepartamento de Diagnóstico por Imagem da Escola Paulista de Medicina da UNIFESP, Rua Napoleão de Barros, 800 Vila Clementino, 04024-002 São Paulo, SP, BrazilWeb of Scienc

Analysis of Learning Curves for Transpedicular Puncture

Objective The authors propose the analysis of quantitative and qualitative learning curves of transpedicular puncture in a manikin-type training simulator model for transpedicular puncture (SMTP) Methods Six students (S1 to S6) were selected to perform the puncture training under radiological control. Quantitative parameters such as the procedure time (total time spent in performing each procedure) and fluoroscopy time (fluoroscopy usage time for each punch) were analyzed using the Mann-Whitney test. For the qualitative evaluation, the punctures were categorized into type AB (adequate) or CD (inadequate) according to the path and positioning of the needle. Qualitative data were analyzed by Fisher's exact test. Results The curves of the examination times and fluoroscopy decreased steadily as expected, especially for the trainee S3. In addition, there was a predominance of punctures AB of the third subsequent sessionhowever, this result was statistically significant for the S1 and S2 trainees. Conclusion The learning curves indicate that qualitative performance improves as students become more familiar with the process.Univ Fed Sao Paulo, Dept Diagnost Imaging, Escola Paulista Med, Sao Paulo, SP, BrazilDepartment of Diagnostic Imaging, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, BrazilWeb of Scienc

Diffusion-Weighted Imaging with Color-Coded Images: Towards a Reduction in Reading Time While Keeping a Similar Accuracy

The aim of this study was to develop a diagnostic tool capable of providing diffusion and apparent diffusion coefficient (ADC) map information in a single color-coded image and to assess the performance of color-coded images compared with their corresponding diffusion and ADC map. The institutional review board approved this retrospective study, which sequentially enrolled 36 head MRI scans. Diffusion-weighted images (DWI) and ADC maps were compared to their corresponding color-coded images. Four raters had their interobserver agreement measured for both conventional (DWI) and color-coded images. Differences between conventional and color-coded images were also estimated for each of the 4 raters. Cohen’s kappa and percent agreement were used. Also, paired-samples t-test was used to compare reading time for rater 1. Conventional and color-coded images had substantial or almost perfect agreement for all raters. Mean reading time of rater 1 was 47.4 seconds for DWI and 27.9 seconds for color-coded images (P=.00007). These findings are important because they support the role of color-coded images as being equivalent to that of the conventional DWI in terms of diagnostic capability. Reduction in reading time (which makes the reading easier) is also demonstrated for one rater in this study