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Neuroimaging H.M.: a 10-year follow-up examination.

In 1997, Corkin et al. described the anatomical boundaries of the amnesic patient H.M.'s surgical resection, based on a comprehensive analysis of magnetic resonance imaging (MRI) scans collected in 1992 and 1993 (Corkin et al. (1997) J Neurosci 17:3964-3979). We subsequently scanned H.M. on several occasions, employing more advanced data acquisition and analysis methods, and now describe additional details about his brain anatomy and pathology. This account combines results from high-resolution T1-weighted scans, which provide measures of cortical and subcortical morphometry, diffusion tensor images, which provide quantitative information about white matter microstructure and the anatomy of major fasciculi, and T2-weighted images, which highlight damage to deep white matter. We applied new MRI analysis techniques to these scans to assess the integrity of areas throughout H.M.'s brain. We documented a number of new changes, including cortical thinning, atrophy of deep gray matter structures, and a large volume of abnormal white matter and deep gray matter signal. Most of these alterations were not apparent in his prior scans, suggesting that they are of recent origin. Advanced age and hypertension likely contributed to these new findings.

Aged↗

Cerebellar metabolic symmetry in essential tremor studied with 1H magnetic resonance spectroscopic imaging: implications for disease pathology.

The pathological basis for essential tremor (ET) is not known; however, metabolic changes in the cerebellum can be observed in positron emission tomography (PET) and (1)H magnetic resonance spectroscopic imaging (MRSI) studies. Tremor is relatively symmetric in ET, suggesting that underlying metabolic changes could be also symmetric. The degree of metabolic asymmetry in the cerebellum, however, has not yet been studied in ET, and knowledge about distribution and laterality of metabolic changes might shed some light on basic disease mechanisms. We measured brain metabolism (N-acetylaspartate[NAA]/creatine [tCR]) to obtain an asymmetry index for cerebellar cortical metabolism ET patients compared with that in controls. This index, a percentage, was calculated as [absolute value (value right - value left)]/(value right + value left) x 100. Multislice (1)H MRSI data were acquired for 20 patients and 11 controls. In ET patients, mean right and left cerebellar cortical NAA/tCR values were 1.61 +/- 0.42 and 1.55 +/- 0.38, respectively, compared with 1.81 +/- 0.62 and 1.87 +/- 0.49 in controls. The difference between right and left cerebellar cortical NAA/tCR was also calculated for each subject. In ET patients, the mean right-left difference was 0.14 +/- 0.11, compared with 0.32 +/- 0.27 in controls (P = 0.016). The mean cerebellar cortical asymmetry index was low in ET (8.8 +/- 6.1%), one-half of that in controls (17.0 +/- 13.7%, P = 0.027). These data suggest that pathological lesions in ET patients, which remain elusive, might be distributed similarly in each cerebellar cortex. Postmortem studies are needed to confirm these preliminary imaging results.

Cerebellum↗

Nasal cavity and paranasal sinus bony variations: a computed tomographic study.

Variations of the nasal cavity are very important for the otolaryngologist in functional endoscopic sinus surgery. To provide data on bony variations of this region, we performed high resolution computed tomography images of paranasal sinuses on 82 adult patients without sinus pathology and on 90 adult patients with sinus disease. We observed paradoxical curvature of the middle concha in 11 (12.22%) sinus patients and 6 (7.31%) in non-sinus patients. Concha bullosa was observed in 26 sinus patients (28.88%) and 22 (26.83%) in non-sinus patients, deviated nasal septum in 20 (22.22%) sinus and 10 (12%) non-sinus, Haller's cell in 5 (5.55%) sinus and in 3 (3.65%) non-sinus, agger nasi cell in 7 (7.77%) sinus and 4 (4.88%) non-sinus patients. Pneumatisation of cristae galli was observed in 8 (8.88%) sinus and 2 (2.44%) non-sinus, of the anterior clinoid process in 5 (5.55%) sinus and 1 (1.22%) non-sinus patients, pneumatisation of the nasal septum in 7 (7.77%) and of the pterygoid recess in 12 (13.33%) sinus patients. We did not find any correlation between age intervals and paranasal sinus variations, and also no statistically significant difference was observed between males and females. These data provide very important information to guide the otolaryngologist and/or radiologist in the evaluation of patients with coronal CT which guides functional endoscopic sinus surgery.

Adult↗

The microcomputer and image analysis in diagnostic pathology.

This paper presents a snapshot view of the influence and direction of microcomputer technology for image analysis techniques in diagnostic pathology. Microcomputers have had considerable impact in bringing image analysis to wider application. Semi-automated tracing techniques are a simple means of providing objective data and assist in a wide range of diagnostic problems. From the common theme of reducing subjectivity in diagnostic assessment, an extensive body of research has accrued. Some studies have addressed the need for quality control for reliable, routine application. Video digitizer cards bring digital image analysis within the reach of laboratory budgets, providing powerful tools for investigation of a wide range of cellular and tissue features. The use of staining procedures compatible with quantitative evaluation has become equally important. As well as assisting scene segmentation, cytochemical and immunochemical staining techniques relate the data to biological processes. With the present state of the art, practical use of microcomputer based image analysis is impaired by limitations of information extraction and specimen throughput. Recent advances in colour video imaging provide an extra dimension in the analysis of multi-spectral stains. Improvements will also be felt with predictable increase in speed of microprocessors, and with single chip devices which deliver video rate processing. If the full potential of this hardware is realized, high-speed, routine analysis becomes feasible. In addition, a microcomputer imaging system can play host to companion functions, such as image archiving and transmission. With this outlook, the use of microcomputers for image analysis in diagnostic pathology is certain to increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Digital imaging guidelines for pathology: a proposal for general and academic use.

Digital imaging is an inexpensive and widely available tool that is used by most pathologists in patient reports, education, publication, diagnosis, and data archival. Its popularity is due, in part, to the ease of modifying, storing, enhancing, and annotating images. Since digital manipulation is essentially undetectable in the final product, it poses the potential risk for fraudulent manipulation and heightens the possibility of unintentional misrepresentation. In an attempt to ensure a high degree of uniformity and quality, and to create a professional standardization amongst pathologists, digital imaging guidelines are proposed for use in general and academic practice.

Education, Medical↗

In vivo study of online liver tissue classification based on envelope power spectrum analysis.

An ultrasonic imaging and signal analysis system, combining a 3.5 MHz linear array B-scanner and an array processor, has been realized for a clinical liver tissue classification study. Based on the complete unprocessed rf data set of a real time B-image, local envelope power spectra averaged over interactively defined regions are computed. These spectra are partially corrected for several tissue type independent effects that affect comparability. A library containing the in vivo data of 65 patients with known liver tissue states in three groups (normal, cirrhotic, fat) was built up. An algorithm based on numerical optimization of parametrized spectrum characteristics combined with a k-nearest-neighbors classifier, applied to the library, leads to correct classification rates of 85.8 to 87.5 percent in discriminating pathological from normal tissue states. The method can be used for k-weighted color coded tissue type imaging with acceptable spatial resolution.

Algorithms↗

[MRI study of the tissue volume progression of lower limbs in hemiplegic subjects].

OBJECTIVES: The aim of this paper was to present the first results of a study about lower limbs' soft tissues (fat and muscle) evolution using magnetic resonance images. MATERIALS AND METHODS: Magnetic resonance images method (MRI) was chosen instead of X-ray scanner for its non-invasive and non-radiating properties. Three hemiplegics volunteers were followed during the first 6 months of their therapy. Lower limbs' MRI captures were made at the beginning and in the end of this period. Computerized processing of the data allows automatic recognition of the main lower limb's tissues. Volumes were determined from images and classified in 4 categories (i.e. muscle, fat, spongy bone, cortical bone). RESULTS: Data analysing showed a different evolution of soft tissues in healthy lower limb compared to pathological lower limb. DISCUSSION-CONCLUSION: This results should lead us to a better understanding of therapeutic efficiency.

Adipose Tissue↗

Integration of medical imaging into a multi-institutional hospital information system structure.

The Department of Veterans Affairs (VA) is providing integrated text and image data to its clinical users at its Washington and Baltimore medical centers and, soon, at nine other medical centers. The DHCP Imaging System records clinically significant diagnostic images selected by medical specialists in a variety of departments, including cardiology, gastroenterology, pathology, dermatology, surgery, radiology, podiatry, dentistry, and emergency medicine. These images, which include color and gray scale images, and electrocardiogram waveforms, are displayed on workstations located throughout the medical centers. Integration of clinical images with the VA's electronic mail system allows transfer of data from one medical center to another. The ability to incorporate transmitted text and image data into on-line patient records at the collaborating sites is an important aspect of professional consultation. In order to achieve the maximum benefits from an integrated patient record system, a critical mass of information must be available for clinicians. When there is also seamless support for administration, it becomes possible to re-engineer the processes involved in providing medical care.

Baltimore↗

Visualization of microvascularity in glioblastoma multiforme with 8-T high-spatial-resolution MR imaging.

We used 8-T high-spatial-resolution gradient-echo MR imaging to directly visualize microvascularity in pathologically proved glioblastoma multiforme. Images were compared with 1.5-T high-spatial-resolution fast spin-echo T2-weighted images and digital subtraction angiograms. Preliminary data indicate that 8-T high-spatial-resolution MR imaging may enable the identification of areas of abnormal microvascularity in glioblastoma multiforme that are not visible with other routine clinical techniques.

Adult↗

Pancreatic diseases: evaluation with MR cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic modality capable of producing high-quality images of the biliary tree and pancreatic duct. We evaluated the MRCP capability of depicting the normal pancreatic duct and, based on data achieved, studied the usefulness in the pathologic pancreatic duct. MRCP was performed in 42 patients without any pancreatic lesion and in 162 patients with pancreatic diseases, including congenital anomalies of biliary tree and pancreatic duct. Results were compared with endoscopic retrograde cholangiopancreatography (ERCP) in 93 patients. The visualization of the pancreatic duct and its branches and the presence or absence of dilatation, stenosis, and filling defects were recorded. All images were interpreted retrospectively and blindly by three radiologists. Among control patients, the main pancreatic duct (MPD) was depicted in the head, body, and tail of the pancreas in 41 (98%), 39 (93%), and 31 (74%), and accessory pancreatic duct and secondary branches in the head, body, and tail of the pancreas were depicted in 11 (26%), eight (19%), four (10%), and two (5%) of these patients. Compared with ERCP, MRCP overestimated the stenosis of MPD and underestimated the dilatation of the branches and filling defects in the pancreatic duct in pancreatic diseases, especially pancreatitis. However, MRCP was distinctly advantageous over ERCP in diagnosing mucin-producing tumor of the pancreas, cystic lesions, and depicting the whole, including the part distal to the obstructed site. Four of the eight cases of pancreas divisum, and 10 of the 12 cases of anomalous pancreaticobiliary duct union also were demonstrated. MRCP can accurately demonstrate the normal pancreatic duct as well as various pancreatic duct abnormalities, including congenital anomalies of the biliary tree and pancreatic duct.

Adolescent↗

Vaginal discharge and bleeding in girls younger than 6 years.

PURPOSE: Persistent unexplained vaginal discharge or bleeding in the pediatric population may be the only manifestation of a serious underlying medical or social problem. Therefore, these symptoms require careful and complete evaluation to identify the primary pathology accurately. We retrospectively reviewed charts of patients who presented for evaluation of persistent vaginal discharge or bleeding to determine if noninvasive imaging was a sensitive means of screening for gynecological pathology. MATERIALS AND METHODS: The records of 24 girls younger than 6 years who presented with vaginal discharge or bleeding were reviewed retrospectively. All patients were evaluated with noninvasive imaging, a pelvic examination while under anesthesia, vaginoscopy and cystoscopy. RESULTS: Noninvasive imaging was useful in identifying 5 of 7 vaginal foreign bodies. However, noninvasive imaging identified only 2 of 6 malignancies. These malignancies consisted of rhabdomyosarcoma (3 patients) and endodermal sinus tumor (3). Two girls also had benign vaginal mullerian papillomas that were not identified by noninvasive imaging. Noninvasive imaging did not aid in the diagnosis of sexual abuse. CONCLUSIONS: Based on these data, we recommend that all girls younger than 6 years who present with persistent vaginal discharge or bleeding be evaluated with pelvic examination while under anesthesia, to be followed by vaginoscopy and cystoscopy if no readily identifiable pathology is found by simple genital examination alone, regardless of the results of noninvasive imaging studies.

Child, Preschool↗

The use of X-terminals as clinical workstations.

The Medical Computer Facility at the Fox Chase Cancer Center has installed X-terminals in patient examination rooms and at nursing stations for clinical data access by physicians and nurses. The X-terminals are connected to UNIX operating system RISC processors via Ethernet. The RISC processors communicate with databases on a minicomputer cluster. Simultaneous presentation of textual (e.g., pathology and radiology reports) and graphical (e.g., clinical laboratory results) clinical data is provided under X-Windows. CT and MRI images can also be displayed in windows. Our experiences implementing X-terminal clinical workstations in a production environment will be discussed.

Cancer Care Facilities↗

Skeletal 3-D CT: advantages of volume rendering over surface rendering.

Both surface rendering and volume rendering have been extensively applied to CT data for 3-D visualization of skeletal pathology. The review illustrates potential limitations of each technique by directly comparing 3-D images of bone pathology created using volume rendering and surface rendering. Surface rendering show gross 3-D relationships most effectively, but suffer from more stairstep artifacts and fail to effectively display lesions hidden behind overlying bone or located beneath the bone cortex. Volume-rendering algorithms effectively show subcortical lesions, minimally displaced fractures, and hidden areas of interest with few artifacts. Volume algorithms show 3-D relationships with varying degrees of success depending on the degree of surface shading and opacity. While surface rendering creates more three-dimensionally realistic images of the bone surface, it may be of limited clinical utility due to numerous artifacts and the inability to show subcortical pathology. Volume rendering is a flexible 3-D technique that effectively displays a variety of skeletal pathology with few artifacts.

Algorithms↗

Hypophysitis.

Hypophysitis is an uncommon inflammatory condition that may affect the pituitary gland and stalk. Patients often present with varying degrees of hypopituitarism. The diagnosis is often made presumptively based on clinical history and biochemical data but may also be supported by magnetic resonance imaging. Therapy is generally supportive in nature but may require surgery for pathological diagnosis and treatment of mass effect.

Algorithms↗

Outcome and staging evaluation in malignant germ cell tumors of the ovary in children and adolescents: an intergroup study.

PURPOSE: The aim of this study was to perform an evaluation of outcome and the role of surgical staging components in malignant germ cell tumors (GCT) of the ovary in children and adolescents. METHODS: From 1990 to 1996, 2 intergroup trials for malignant GCT were undertaken by Pediatric Oncology Group (POG) and Children's Cancer Study Group (CCG). Stage I-II patients were treated with surgical resection and 4 cycles of standard dose cisplatin (100 mg/m2/cycle), etoposide, and bleomycin (PEB) chemotherapy. Stage III-IV patients were treated with surgical resection and randomly assigned to chemotherapy with PEB or high-dose cisplatin (200 mg/m2/cycle) with etoposide and bleomycin (HDPEB). Patients unresectable at diagnosis had second-look operation after 4 cycles of chemotherapy if residual tumor was seen on imaging studies. IRB approval of the protocols was obtained at each participating institution. An analysis of outcome data, operative notes, and pathology reports in girls with ovarian primary site was done for this report. RESULTS: There were 131 patients with ovarian primary tumors of 515 entered on these studies. Mean age was 11.9 years (range, 1.4 to 20 years). Six-year survival rate was stage, I 95.1%; stage II, 93.8%; stage III, 98.3%; stage IV, 93.3%. In only 3 of 131 patients were surgical guidelines followed completely. Surgical omissions resulting in protocol noncompliance resulted from failure to biopsy bilateral nodes (97%), no omentectomy (36%), no peritoneal cytology (21%), no contralateral ovary biopsy (59%). More aggressive procedure than recommended by guidelines included total hysterectomy and bilateral salpingo-oophorectomy in 6 patients and retroperitoneal node dissection in 10 patients. Correlation of gross operative findings with pathology results was carried out for ascites, lymph nodes, implants, omentum, and contralateral ovary. CONCLUSIONS: Pediatric ovarian malignant GCT (stages I-IV) have excellent survival with conservative surgical resection and platinum-based chemotherapy. Survival appears to have been unaffected by deviations from surgical guidelines. New surgical guidelines are proposed based on correlation of gross findings, histology, and outcome in these intergroup trials.

Adolescent↗

Semiautomated thermal lesion segmentation for three-dimensional elastographic imaging.

Several studies have demonstrated that lesion volumes computed from multiple planar slices through the region-of-interest (ROI) are more accurate than volumes estimated assuming simple shapes and incorporating single or orthogonal diameter estimates. However, manual delineation of boundaries on multiple planar 2-D images is tedious and labor-intensive. Automatic extraction of lesion boundaries is, therefore, attractive and imperative to remove subjectivity and reduce assessment time. This paper presents a semiautomated segmentation algorithm for thermal lesions on 3-D elastographic data to obtain both area and volume information. The semiautomated segmentation algorithm is based on thresholding and morphologic opening of both 2-D and 3-D elastographic data. Results obtained on 44 thermal lesions imaged in vitro using elastography were compared to manual delineation of both elastographic and pathology images. Results obtained using semiautomated segmentation demonstrate a close correspondence with manual delineation results. However, area and volume estimates obtained using both manual and semiautomated segmentation of lesions seen on elastograms slightly underestimate areas and volumes measured from pathology.

Algorithms↗

Aggressive resection is indicated for cecal diverticulitis.

BACKGROUND: Because of the difficulties in preoperative diagnosis and controversies in the management, cecal diverticulitis has received much discussion in the literature. There, however, are still many questions that remain unanswered. METHODS: During a 5-year period, 112 patients with a clinical diagnosis of cecal diverticulitis were treated. Twenty-seven patients were excluded because of uncertainty in diagnosis or incomplete data collection, leaving 85 patients as the study group. The diagnosis of cecal diverticulitis was made by pathology, surgical findings, or image study. RESULTS: Nonoperative management was applied to 18 patients initially. Three patients had recurrent diverticulitis during follow up. These patients responded satisfactorily to another course of medical treatment. Laparotomy was performed in 67 patients. Acute appendicitis was the preoperative diagnosis in 47 patients (70%). Of the other 20 patients, 6 received operation because of repeated attack of diverticulitis, 7 had preoperative computed tomography (CT) diagnosis of cecal diverticulitis with perforation, 5 had preoperative diagnosis of cecal tumor, and 2 had medical treatment failure. All these 20 patients received right hemicolectomy. In the 47 patients with a preoperative diagnosis of acute appendicitis, 24 received appendectomy, 9 received diverticulectomy, and 14 received right hemicolectomy. Overall, 34 patients received right hemicolectomy, 9 received diverticulectomy, and 24 received appendectomy only. In the right hemicolectomy group, there were 2 deaths with underlying diseases and 5 complications. In the appendectomy group, there was no postoperative mortality, but in 7 patients recurrent diverticulitis developed. Three of them required right hemicolectomy. CONCLUSIONS: The natural history of cecal diverticulitis varies from benign and self-limiting to fulminant in the oriental population. Less than 40% (32 of 85) of patients were successfully treated with conservative methods initially and had no recurrence during the follow-up period. We recommend aggressive surgical resection for patients with a definite diagnosis. Adjuvant appendectomy without resection of the lesion should be considered only in uncomplicated patients whose diagnosis is in doubt.

Acute Disease↗

Renal cell carcinoma: incidental detection during routine ultrasonography in men presenting with lower urinary tract symptoms.

OBJECTIVE: To compare renal cell carcinomas (RCCs) presenting incidentally in patients referred for lower urinary tract symptoms (LtJTS) with those presenting symptomatically, by stage, intervention and outcome. PATIENTS AND METHODS: The case notes of all male patients (100) diagnosed with RCC between 1991 and 1998 were reviewed and modes of presentation recorded. The patients were divided into two groups: those who were referred with LUTS (frequency, urgency, hesitancy, poor stream, nocturia) and in whom RCC would not have been suspected and was thus detected incidentally on routine ultrasonography; and all patients in whom carcinoma might have been suspected from their symptoms but, for the purposes of this study, also included patients in whom RCC was diagnosed during ultrasonography for unrelated intra-abdominal pathology. Details of diagnostic imaging and clinical staging were similarly recorded for both groups and where surgical intervention was undertaken, histopathological data were also noted. The clinical course and long-term outcome of incidentally detected tumours was then compared with their symptomatically presenting counterparts. RESULTS: The mean (range) follow-up for all patients was 30 (1.5-96) months; for those in the incidental group it was 31 (1-86) months and in the symptomatic patients 29 (1-96) months. Organ-confined disease was found in two-thirds of patients with incidental tumours and in 38% of those in whom the tumour may have been suspected; the difference was statistically significant (chi-squared test P<0.05). The mean (SD) size of tumours discovered incidentally and in symptomatic patients was 5.9 (1.94) cm and 9.2 (3.39) cm, respectively; this difference was also statistically significant (t-test, P<0.001). Of the 24 patients with incidentally detected tumours, 14 (58%) were alive with no recurrence, and of the 76 presenting symptomatically, 27 (35%) were alive with no recurrence at the last follow-up; disease survival curves showed a statistically better survival rate for those with organ-confined tumours. CONCLUSION: Incidentally diagnosed RCC represents a significant proportion of those who are ultimately diagnosed with the malignancy. Opportunities which arise for appropriate screening of the upper tracts during routine urological investigations (e.g. ultrasonography of the upper tracts in patients referred for LUTS) should be endorsed, contrasting with the more traditional approach, which argues that it yields no ultimate survival advantage.

Carcinoma, Renal Cell↗