Aim: We estimated the usefulness of our new scale to rate medial temporal atrophy with short inversion time inversion recovery images. Methods: Alzheimer's disease (AD) subjects (n = 34) and non-demented subjects (n = 19) were recruited for this study. First, coronal short inversion time inversion recovery images were scanned vertical to the long axis of hippocampus. Next, the single image in which peduncles appeared widest was adopted for estimation. The parahippocampal cerebrospinal fluid space was divided into three parts: the outer, upper and inner parts. The hippocampus was defined as a structure being of equal intensity to grey matter. Two radiologists compared each part of the parahippocampal cerebrospinal fluid space with the hippocampus and rated them on a 0-3 scale. Interrater and intrarater kappa statistics and sensitivity/specificity for the diagnosis of AD were calculated using the scores of the right, left and both sides combined. Results: There were no significant differences between AD and ND subjects with regards to sex. AD subjects had lower Mini-Mental State Examination scores and were older than non-demented subjects. Interrater and intrarater kappa statistics were 0.52-0.68 and 0.76-0.83, respectively. Sensitivity was 88.2% using the scores of both sides. Conclusions: Interrater and intrarater agreements were fair to good and good to excellent, respectively. Our new visual rating method detected medial temporal atrophy in AD patients at a highly sensitive rate. As such, we conclude that this visual rating scale is useful for judging medial temporal atrophy simply and objectively in clinical use, and it is helpful in establishing an AD diagnosis.
Crossed cerebellar diaschisis (CCD) is an interesting phenomenon which classically refers to the depressed blood flow and metabolism affecting one cerebellar hemisphere after a contralateral hemispheric infarction. However, CCD can also be caused by a prolonged seizure. We herein report a case of CCD due to status epilepticus in a patient who showed unique magnetic resonance imaging findings. Case ReportA 67-year-old man with a history of alcoholism was transferred to our hospital with convulsive status epilepticus (SE). Three months earlier, he had caused a traffic accident while driving to the neighboring prefecture and was admitted to the nearest general hospital. He had no apparent traumatic injuries but experienced a single convulsive seizure in the emergency room. He was discharged with a recommendation to consult a physician at his local hospital, which he did not follow.On admission, he presented with repetitive generalized tonic-clonic seizures that first affected the right side of his face and upper right arm. His Glasgow coma scale (GCS) score was E1V2M4. A physical examination revealed that his blood pressure was 112/88 mm Hg, his heart rate was 153 bpm, and his body temperature was 39.4 . Brain computed tomography only revealed mild cerebral atrophy. His blood tests results were as follows: hemoglobin, 17.0 g/dL; white blood cell count, 12,550/mm 3 ; platelets, 132,000/mm 3 ; serum total bilirubin, 2.60 mg/dL; aspartate aminotransferase, 259 IU/L; alanine aminotransferase, 88 IU/L; γ-glutamyl transpeptidase, 1,376 IU/L; creatinine phosphokinase, 976 IU/L; albumin, 3.5 g/L; creatinine, 1.52 mg/dL; and blood urea nitrogen, 17.8 mg/dL. His blood levels of vitamin B1, vitamin B12, and folic acid were normal (4.1 μg/ dL, 670 pg/mL, and 5.1 ng/mL, respectively). A cerebrospinal fluid (CSF) analysis showed a normal cell count and glucose level and a moderately elevated total protein concentration (75 mg/dL, normal range: 10-40 mg/dL). A polymerase chain reaction test for herpes simplex virus in CSF was negative. Artificial ventilation and the intravenous administration of midazolam and fosphenytoin sodium hydrate were initiated, but his convulsive seizure was intractable. Electroencephalography revealed left periodic lateralized epileptiform discharges characterized by rhythmic delta waves over the left frontal, central, and mid-temporal regions (Fig. 1). On brain magnetic resonance imaging (MRI), fluid-attenuated inversion recovery (FLAIR) and diffusionweighted images (DWI) revealed marked hyperintensity and gyral swelling in the cortex of the left hemisphere and the contralateral cerebellum with a corresponding low apparent diffusion coefficient (ADC) (Fig. 2A). Increased flow in the branches of the left middle cerebral artery (MCA) was evident on magnetic resonance angiography (Fig. 3). These findings were consistent with left hemispheric status epilepticus with crossed cerebellar diaschisis (CCD). The DWI
We investigated the pathogenic relationship between cerebral microbleeds and lacunar strokes. Two cases of lacunar strokes in the region of the basal ganglia, a 72-year-old man and a 67-year-old man, were studied; both cases showed cerebral microbleeds in the stroke areas. The cerebral microbleeds were surrounded by oedema, and the oedema faded out over time, suggesting the cerebral microbleeds had developed acutely. The cerebral microbleeds were located at the ventrolateral edge of the lacunar infarctions, and the locations appeared to be at or near the sites of occlusion of the lenticulostriatal branches. Although a cerebral microbleed and a lacunar infarction may be two unrelated events on juxtapositioned vessels, or a cerebral microbleed may be haemorrhagic conversion of an infarction, a cerebral microbleed could cause an occlusion of the arterial branch, leading to lacunar infarction of its supplying territories.
Question: A 15-month-old boy presented with afebrile convulsion and impaired consciousness owing to marked hypokalemia. He was referred by a community hospital where he had presented with a first episode of nonbilious vomiting 3 days previously. Physical examination revealed a hard, egg-sized epigastric mass. Plain radiography demonstrated a gasdistended stomach. As part of the workup for the mass, the infant underwent ultrasonography (Figure A) and abdominal computed tomography scan (Figure B, C). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
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