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Pregnancy-related cerebrovascular disease is a serious complication of pregnancy and puerperium. The etiology and pathological mechanisms of cerebrovascular disease are complex, involving changes in the cardiovascular, endocrine, and immune systems. Vascular risk factors during pregnancy and puerperium may cause vasospasm and endothelial cell damage leading to cerebral ischemia, hemorrhage, posterior reversible encephalopathy syndrome (PRES), and reversible cerebral vasoconstriction syndrome. Arterial or venous obstruction may damage the blood-brain barrier (BBB) and impede venous return, resulting in cerebral edema, hemorrhage, and intracranial hypertension. Pregnancy with hypercoagulability may threaten the lives of both the mother and the developing fetus. With improvements in stroke treatment during pregnancy and puerperium, neuroradiologists have gained new insights into this problem. This article reviews the pathogenesis, imaging findings, and risk factors of stroke during pregnancy and puerperium, focusing on imaging diagnosis and prognostic assessment.

Posterior reversible encephalopathy syndrome (PRES) represents a unique clinical entity with non-specific clinical symptoms and unique neuroradiological findings. This syndrome may present with a broad range of clinical symptoms from headache and visual disturbances to seizure and altered mentation. Typical imaging findings include posterior-circulation predominant vasogenic edema. Although there are many well-documented diseases associated with PRES, the exact pathophysiologic mechanism has yet to be fully elucidated. Generally accepted theories revolve around disruption of the blood-brain barrier secondary to elevated intracranial pressures or endothelial injury. In this article, we will review the clinical, typical, and atypical radiological features of PRES, as well as the most common theories behind the pathophysiology of PRES. Additionally, we will discuss some of the treatment strategies for PRES related to the underlying disease state.

The roles of clinical etiology and symptoms, imaging findings and biochemical parameters in predicting the prognosis of posterior reversible encephalopathy syndrome (PRES) have not been well-characterized. We perform a meta-analysis of all published studies to assess the value of various risk factors in predicting the prognosis of PRES.Searches of the PubMed, EMBASE, Cochrane Library, and Web of Science databases were performed to identify the eligible studies. The odds ratios (ORs) with their corresponding 95% confidence interval (CI) for related risk factors were used to calculate the pooled estimates of the outcomes.Six studies with 448 cases were included in the meta-analysis. Hemorrhage was associated with high risk for poor outcome in patients with PRES. Toxemia of pregnancy (pre-eclampsia/eclampsia) was associated with improved outcome in PRES patients. Cytotoxic edema was noted to be related to poor outcome, but did not show statistical significance. The pooled OR for hemorrhage, pre-eclampsia/eclampsia, cytotoxic edema was 4.93 (95% CI: 3.94-6.17; P0.00001), 0.24 (95% CI: 0.15-0.40; P0.00001) and 2.59 (95% CI: 0.84-7.99; P=0.10), respectively.PRES patients with hemorrhage or cytotoxic edema are likely to have poor outcomes. Pre-eclampsia/eclampsia is associated with reduced risk of poor outcome in patients with PRES.

Cervical intramedullary spinal cord abscess is an extremely rare entity. We present a case of a 53-year-old male with a cervical intramedullary spinal cord abscess caused by Streptococcus viridians that presented with 4 days of neck pain and progressive left upper extremity numbness and weakness. The patient was managed with a cervical myelotomy and adjunctive antibiotic treatment.

A 31 year-old man with HIV and pulmonary tuberculosis (TB) status-post RIPE regimen presented with cough and throbbing headaches. Laboratory results were remarkable for a CD4 count of 2 kcells/L and a viral load of 2.7 million copies/mL. MRI of the brain reported multiple lobulated and cystic intracranial lesions associated with the dura that had thick rinds of enhancement. CT of the chest, abdomen and pelvis demonstrated axillary and inguinal lymphadenopathy, a mass within the right pelvis thought to represent necrotic lymph nodes, prominence of the right psoas muscle, a cystic nodule in the liver, and a right adrenal lesion. The patient was started on dexamethasone, RIPE therapy, and empiric antimicrobial therapy. He subsequently underwent stealth-guided brain biopsy and open craniotomy. Pathology returned a tissue diagnosis of an AIDS related EBV-associated smooth muscle tumor (EBV-SMT) best categorized as a malignant myopericytoma. Following surgery, the patient began additional anti-retroviral therapy for HIV and was discharged. Despite treatment, three to four months following discharge the patient's symptoms progressed and he was found to have developed a severe bilateral homonymous hemianopsia. Repeat MRI demonstrated tumor growth and the patient subsequently received whole brain radiation along with sirolimus and pomalidomide. Approximately two months following radiation therapy the patient had increasing headaches along with nausea and vomiting. Repeat MRI was consistent with radiation arrested tumor growth but did not show any decrease in size of his intracranial lesions. Therapy with bevacizumab was initiated and he had marked improvement of his visual field deficits. The patient has since completed 20 cycles of treatment with bevacizumab and is currently 17 months post his initial diagnosis. Repeat imaging has demonstrated decreasing size of his lesions and no new lesions have developed.

Over two decades have passed since posterior reversible encephalopathy syndrome (PRES) was first described in 1996. It has becoming increasingly recognised because of improved and more readily available imaging modality. The exact pathophysiological mechanism is not completely understood and remains controversial at present. Precise diagnosis is essential to guide prompt, proper management. Our ability of differentiating it from other acute neurological disorders is likely to improve as we learnt more about the spectrum of this entity in the last 20 years. We emphasise the importance of recognising its diagnostic criteria and biomarker, which would be of great relevance to either outcome evaluation or study design. PRES has a favourable prognosis generally, but neurological sequelae and even fatalities can occur, especially in severe forms that might cause substantial morbidity and even mortality, particularly when the syndrome is complicated by intracranial haemorrhage or brain infarction. In this review, the pathophysiology, approach to diagnosis, some controversies as to the prognosis, as well as the future research direction of PRES are described.

Background: To explore blood–brain barrier disruption in hypertensive posterior reversible encephalopathy syndrome.Methods: The hypertension rat models were successfully established and scanned on 7T micro-MRI. MRI parameter maps including apparent diffusion coefficient, T1 value, and perfusion metrics such as cerebral blood volume, cerebral blood flow, mean transit time and time to peak maps, were calculated.Results: The ADC values of the experimental group were higher than those of the control group both in cortical (P < 0.01) and subcortical (P < 0.05) regions. Voxel-wise analysis of ADC maps localized vasogenic edema primarily to the posterior portion of the brain. The increase in cerebral blood volume and cerebral blood flow values were found in the cortical and subcortical regions of rats with acute hypertension. No correlation was found between perfusion metrics and mean arterial pressure. The Evans blue dye content was higher in the posterior brain region than the anterior one (P < 0.05).Conclusions: Cerebral vasogenic edema resulting from acute hypertension supports the hypothesis of posterior reversible encephalopathy syndrome as the result of blood–brain barrier disruption, which maybe the potential therapeutic target for intervention.

Objective: Diffusion-weighted imaging (DWI)-Alberta Stroke Program Early CT Score (ASPECTS) is a simple, widely used method to estimate the size of the infarct. Our aim is to determine whether there is a relationship between DWI-ASPECTS and fluid-attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH)-DWI mismatch and to better quantify FVH-DWI mismatch to assess the prognosis of cerebral infarction.Materials and Methods: A retrospective analysis of 109 patients with MCA stenosis or occlusion with cerebral infarction was performed by dividing this cohort into FVH-DWI match group and FVH-DWI mismatch group based on FVH and DWI results. The clinical and imaging data of these two groups of patients were reviewed and analyzed to identify associations between FVH-DWI mismatch and prognosis of patients for preservation of neurological function. Correlation between DWI-ASPECTS and FVH-DWI mismatch was also performed.Results: FVH-DWI mismatch was present in 66/109 (60.55%) patients, and FVH-DWI match was present in 43/109 (39.45%). Patients with FVH-DWI mismatch had higher DWI-ASPECTS (7.0 vs. 4.0, P < 0.001) and lower mRS at 3 months (3.0 vs. 4.0, P < 0.001) than patients without FVH-DWI mismatch. Multiple regression analysis suggested that DWI-ASPECTS (OR = 4.7, 95% CI = 2.5–9.2, P < 0.001) remained significantly associated with FVH-DWI mismatch. Two threshold points for DWI-ASPECTS of 3 and 8 can be used to distinguish whether there is a mismatch in FVH-DWI by smooth curve fitting.Conclusions: The DWI-ASPECTS score was an independent predictor of FVH-DWI mismatch. At DWI-ASPECTS ≤ 3, the FVH-DWI mismatch offers no prognostic value; whereas, at DWI-ASPECTS ≥ 8, the FVH-DWI mismatch had the highest prognostic value. DWI-ASPECTS can roughly determine whether there is a FVH-DWI mismatch in order to select optimal clinical treatment and accurately assess prognosis.

Headaches are exceedingly common, but most individuals who seek medical attention with headache will not have a serious underlying etiology such as a brain tumor. Brain tumors are uncommon; however, many patients with brain tumors do suffer from headaches. Generally these headaches are accompanied by other neurologic signs and symptoms. A careful clinical assessment for red flags should be undertaken when considering further work-up with neuroimaging to exclude a serious underlying condition.

This article provides an overview of the neuroimaging literature focused on preoperative prediction of meningioma consistency. A validated, noninvasive neuroimaging method to predict tumor consistency can provide valuable information regarding neurosurgical planning and patient counseling. Most of the neuroimaging literature indicates conventional MRI using T2-weighted imaging may be helpful to predict meningioma consistency; however, further rigorous validation is necessary. Much less is known about advanced MRI techniques, such as diffusion MRI, MR elastography (MRE), and MR spectroscopy. Of these methods, MRE and diffusion tensor imaging appear particularly promising.

A 40-year-old woman was referred to physical therapy with complaints of headaches. Examination raised suspicion of a "thunderclap headache," a condition characterized by sudden, intense headaches correlated with bleeding in and around the brain. The patient was referred to a neurologist, who ordered magnetic resonance angiography of the head and neck, which identified a partial dissection of the right vertebral artery. A subsequent computed tomography angiogram confirmed the dissection.

Cerebrovascular complications may occur in infectious diseases in the setting of infective endocarditis, central nervous system (CNS) infections, systemic bacteremia and sepsis. Cerebrovascular complications of infections include vasculitis, mycotic aneurysms, and thrombophlebitis. Infectious vasculitis of the CNS may cause cerebral hemorrhage, infarction or ischemia. Ruptured aneurysms may endanger the patient's life. Infectious thrombophlebitis may cause intracranial pressure to increase and lead to cerebral hemorrhage. These cerebrovascular complications are associated with a poor prognosis and often cause irreversible neurological deficits. Cerebrovascular events secondary to infection are not easily distinguishable from the more common cerebral infarct and non-infectious vasculitis. In addition, the clinical manifestations of cerebrovascular complications of infections are non-specific and highly variable. Therefore, early imaging, antibiotics, and anticoagulation may be lifesaving the patient's life and prevent disability. The main focus of this article is to review imaging analysis of the cerebrovascular complications of infections and imaging features that help differentiate them from non-infectious vascular diseases.

Inflammatory and autoimmune disorders of the spinal cord are a heterogeneous group of myelopathies with a diverse differential diagnosis. Due to similarities in presentation and diverse associated conditions, confusion can arise in differentiating the key myelopathies. By focusing primarily on the clinical presentation followed by differentiating pathophysiology for the disorders discussed, this chapter aims to provide a foundation for differentiation based on nuances among otherwise similar presentations in these disorders. Diagnostic algorithms and select cases will be discussed with a focus on spinal cord imaging.

In 2016, World Health Organization announced Zika virus infection and its neurological sequalae are a public health emergency of global scope. Preliminary studies have confirmed a relationship between Zika virus infection and certain neurological disorders, including microcephaly and Guillain-Barre syndrome (GBS). The neuroimaging features of microcephaly secondary to Zika virus infection include calcifications at the junction of gray-white matter and subcortical white matter with associated cortical abnormalities, diminution of white matter, large ventricles with or without hydrocephalus, cortical malformations, hypoplasia of cerebellum and brainstem, and enlargement of cerebellomedullary cistern. Contrast enhancement of the cauda equine nerve roots is the typical neuroimaging finding of GBS associated with Zika virus. This review describes the nervous system disorders and associated imaging findings seen in Zika virus infection, with the aim to improve the understanding of this disease. Imaging plays a key role on accurate diagnosis and prognostic evaluation of this disease.

Background: To evaluate the utility of rabbit ladderlike model of radiation-induced lung injury (RILI) for the future investigation of computed tomography perfusion. Methods: A total of 72 New Zealand rabbits were randomly divided into two groups: 36 rabbits in the test group were administered 25 Gy of single fractionated radiation to the whole lung of unilateral lung; 36 rabbits in the control group were sham-radiated. All rabbits were subsequently sacrificed at 1, 6, 12, 24, 48, 72 h, and 1, 2, 4, 8,1 6, 24 weeks after radiation, and then six specimens were extracted from the upper, middle and lower fields of the bilateral lungs. The pathological changes in these specimens were observed with light and electron microscopy; the expression of tumor necrosis factor-α (TNF-a) and transforming growth factor-β1 (TGF-β1) in local lung tissue was detected by immunohistochemistry. Results: (1) Radiation-induced lung injury occurred in all rabbits in the test group. (2) Expression of TNF-a and TGF-β1 at 1 h and 48 h after radiation, demonstrated a statistically significant difference between the test and control groups (each P < 0.05). (3) Evaluation by light microscopy demonstrated statistically significant differences between the two groups in the following parameters (each P < 0.05): thickness of alveolar wall, density of pulmonary interstitium area (1 h after radiation), number of fibroblasts and fibrocytes in interstitium (24 h after radiation). The test group metrics also correlated well with the time of postradiation. (4) Evaluation by electron microscopy demonstrated statistically significant differences in the relative amounts of collagen fibers at various time points postradiation in the test group (P < 0.005), with no significant differences in the control group (P > 0.05). At greater than 48 h postradiation the relative amount of collagen fibers in the test groups significantly differ from the control groups (each P < 0.05), correlating well with the time postradiation (r = 0.99318). Conclusions: A consistent and reliable rabbit model of RILI can be generated in gradient using 25 Gy of high-energy X-ray, which can simulate the development and evolution of RILI.

Background Cognitive deficit associated with cancer and its treatment is called cancer-related cognitive impairment (CRCI). Increases in cancer survival have made understanding the basis of CRCI more important. CRCI neuroimaging studies have traditionally used dedicated research brain MRIs in breast cancer survivors after chemotherapy with small sample sizes; little is known about other non-central nervous system (CNS) cancers after chemotherapy as well as those not exposed to chemotherapy. However, there may be a wealth of unused data from clinically-indicated MRIs that could be used to study CRCI. Objective Evaluate brain cortical structural differences in those with various non-CNS cancers using clinically-indicated MRIs. Design Cross-sectional. Patients Adult non-CNS cancer and non-cancer control (C) patients who underwent clinically-indicated MRIs. Methods Brain cortical surface area and thickness were measured using 3D T1-weighted images. An age-adjusted linear regression model was used and the Benjamini and Hochberg false discovery rate (FDR) corrected for multiple comparisons. Group comparisons were: cancer cases with chemotherapy (Ch+), cancer cases without chemotherapy (Ch-) and subgroup of lung cancer cases with and without chemotherapy vs C. Results Sixty-four subjects were analyzed: 22 Ch+, 23 Ch- and 19 C patients. Subgroup analysis of 16 lung cancer (LCa) patients was also performed. Statistically significant decreases in either cortical surface area or thickness were found in multiple regions of interest (ROIs) primarily within the frontal and temporal lobes for all comparisons. Effect sizes were variable with the greatest seen in the left middle temporal surface area ROI (Cohen's d -0.690) in the Ch- vs C group comparison. Limitations Several limitations were apparent including a small sample size that precluded adjustment for other covariates. Conclusions Our preliminary results suggest that, in addition to breast cancer, other types of non-CNS cancers treated with chemotherapy may result in brain structural abnormalities. Similar findings also appear to occur in those not exposed to chemotherapy. These results also suggest that there is potentially a wealth of untapped clinical MRIs that could be used for future CRCI studies.

To explore the value of 64-section computed tomography (CT) perfusion imaging (CTPI) in the early diagnosis of acute radiation-induced lung injury (ARILI).Fifty-one patients with oesophageal cancers or malignant thymomas received postoperative radiation therapy with a 60-62 Gy dose and underwent CTPI at pre- and post-radiation therapy time points (week 0, week 4, week 8, and week 12 respectively). The CTPI values were prospectively compared and analysed in order to evaluate the diagnostic utility of CTPI in the early diagnosis of ARILI.Eighteen cases (18/51) of ARILI were diagnosed. The mean values of relative regional blood flow (rrBF), relative regional volume (rrBV), and relative regional permeability surface (rrPS) in the ARILI group were correspondingly higher than those of the non-ARILI group. At week 4, rrBF, rrBV, and rrPS in the ARILI group were significantly higher than those at pre-radiation (each p0.05). In the non-ARILI group, rrBF and rrBV were higher than those at pre-radiation (each p0.05); however, rrPS was not statistically different from that of pre-irradiation. Applying the diagnostic threshold value of rrPS = 1.22, the sensitivity, specificity, and positive and negative predictive values of CTPI for early diagnosis of ARILI were better than those of CT.CTPI metrics may reflect haemodynamic changes in the post-irradiation lung and can detect cases of early ARILI that appear normal at CT. CTPI is a promising technique for early diagnosis of ARILI.

Advancements in diffusion-weighted imaging during the past decade have led to the use of diffusion tensor imaging to further characterize the structural integrity of neural tissue and to noninvasively trace neuronal tracts in the brain and spine. This has led to many clinical applications that have aided in surgical planning for brain and spinal cord tumors and has increased the diagnostic potential of magnetic resonance imaging in disorders such as multiple sclerosis, Alzheimer disease, and traumatic brain injury.

A retrospective review was made of intraoperative femoral fracture prevalence in seventy nine consecutive, cementless, fully HA-coated stems used for revision hip arthroplasty. Three patients were lost to follow up. Intraoperative fracture occurred in 15 (20%) femurs. Fractures occurred during cement removal (3/15) or insertion of the implant (12/15). All fractures were identified using intraoperative biplane X-ray, and were treated during the same operation. The clinical outcome of both groups (with or without fractures) was similar. The risk of intraoperative fracture was not statistically related to any demographic features or operative technique. Intraoperative radiographs are therefore mandatory in revision hip arthroplasty in order to diagnose and treat the common complication of femur fracture appropriately.

A 15-year-old male high school football player presented with episodes of headache and complete body stiffness, especially in the arms, lower back, and thighs, immediately following a football game. This was accompanied by severe nausea and vomiting for several days. Viral meningitis was suspected by the primary clinician, and treatment with corticosteroids was initiated. Over the next several weeks, there was gradual symptom improvement and the patient returned to his baseline clinical status. The patient experienced a severe recurrence of the previous myriad of symptoms following a subsequent football game, without an obvious isolated traumatic episode. In addition, he experienced a new left sided headache, fatigue, and difficulty ambulating. He was admitted and an extensive workup was performed. CT and MRI of the head revealed concurrent intracranial and spinal subdural hematomas (SDH). Clinical workup did not reveal any evidence of coagulopathy or predisposing vascular lesions. Spinal SDH is an uncommon condition whose concurrence with intracranial SDH is an even greater clinical rarity. We suggest that our case represents an acute on chronic intracranial SDH with rebleeding, membrane rupture, and symptomatic redistribution of hematoma to the spinal subdural space.

Although conventional contrast-enhanced MR imaging remains the standard-of-care imaging method in the posttreatment evaluation of gliomas, recent developments in therapeutic options such as chemoradiation and antiangiogenic agents have caused the neuro-oncology community to rethink traditional imaging criteria. This article highlights the latest recommendations. These recommendations should be viewed as works in progress. As more is learned about the pathophysiology of glioma treatment response, quantitative imaging biomarkers will be validated within this context. There will likely be further refinements to glioma response criteria, although the lack of technical standardization in image acquisition, postprocessing, and interpretation also need to be addressed.

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome characterized by a variable combination of headaches, seizures, altered mental status, visual impairment, focal neurological signs and symmetric vasogenic edema in bilateral posterior cerebral circulation territory. The pathogenesis of PRES is still controversial. Most of the clinical conditions associated with PRES involve a systemic toxicity response in the entire organism with activation of the cells of the immune system and cytokines. These PRES related conditions induce T cell activation, cytokine release, and subsequent leukocyte adhesion and activation, resulting in endothelial damage and fluid leakage. This potential mechanism of immune system activation and endothelial dysfunction may play a critical role in the pathogenesis of PRES. In this review, the role of immune system activation and endothelial dysfunction in the pathogenesis of PRES is discussed, with the aim to improve our understanding of this disorder.

Because of their complexity, war injuries inflicted by blast mechanism often require tailoring of treatment to attain a more individualized solution. We report a case of paediatric patient who suffered from severe complication after a blast injury to the lower limb with extensive tissue damage and loss.

We read with great interest the article by Karia et al[1][1] on posterior reversible encephalopathy syndrome (PRES) evaluating the association between the presence of enhancement in PRES and various clinical factors in a large series of 176 patients with PRES. They found that the presence or pattern

Central neurocytomas comprise nearly half of adult intraventricular neoplasms. The median age of onset is 34 years. It is typically a low-grade neoplasm (World Health Organization grade II), although some cases of malignant neurocytomas have been described. We present a rare case of an atypical central neurocytoma with craniospinal dissemination, including both imaging and pathologic findings.

We have designed and developed a multiple sclerosis eFolder system for patient data storage, image viewing, and automatic lesion quantification results stored in DICOM-SR format. The web-based system aims to be integrated in DICOM-compliant clinical and research environments to aid clinicians in patient treatments and data analysis. The system needs to quantify lesion volumes, identify and register lesion locations to track shifts in volume and quantity of lesions in a longitudinal study. In order to perform lesion registration, we have developed a brain warping and normalizing methodology using Statistical Parametric Mapping (SPM) MATLAB toolkit for brain MRI. Patients’ brain MR images are processed via SPM’s normalization processes, and the brain images are analyzed and warped according to the tissue probability map. Lesion identification and contouring are completed by neuroradiologists, and lesion volume quantification is completed by the eFolder’s CAD program. Lesion comparison results in longitudinal studies show key growth and active regions. The results display successful lesion registration and tracking over a longitudinal study. Lesion change results are graphically represented in the web-based user interface, and users are able to correlate patient progress and changes in the MRI images. The completed lesion and disease tracking tool would enable the eFolder to provide complete patient profiles, improve the efficiency of patient care, and perform comprehensive data analysis through an integrated imaging informatics system.

Injuries related to natural disasters and wars are typically high-energy trauma or crush injuries. The majority of these are injuries to the musculoskeletal system [1, 2] and more specifically the extremities. Adequate limb stabilization is of major importance. It protects the injured from devastating complications, such as hemorrhage and fat embolisms [3]. High-energy fractures are often open fractures and secondary injuries due to the movement of bone fragments. These processes can lead to an increase in the contamination of bone and soft tissues, resulting in infection, nonunion, and wound healing complications [4]. The rapid and effective stabilization of high-energy trauma wounds can be a life-saving tool in complex trauma patients.

Mass casualties related to either natural or man-made disasters are a reality of our lives, affecting large populations happening in both developed and developing countries. The earthquake that hit Haiti on January 12, 2010, caused around 237,000 deaths and nearly 300,000 wounded and left about 1 million homeless—revealing just how unprepared most countries are to deal with mass casualties and disaster-related injuries. A large percentage of the injuries typically seen in these situations are to the limbs [1, 2]. An overwhelming number of casualties; delayed presentation; crush injuries and crush syndrome; lack of adequate medical facilities and sometimes expertise, regional and cultural; and other factors influence the decision to amputate, to save lives, or to preserve function.

In this report, we tried to evaluate the merits of the classic "reconstructive ladder" and other reconstructive tools, such as acute shortening followed by distraction osteogenesis and a vacuum-assisted closure device, for the treatment of high-energy injuries. Thirty-seven patients suffering from high-velocity injuries to the extremities caused by war weapons and blast terror attacks were treated at our institution. The fractures were initially stabilized by the Association for the Study of Internal Fixation (AO/ASIF) unilateral tubular external fixator, which was changed 2-3 days later to a circular Ilizarov frame for 19 patients. Temporary acute shortening was performed for 5 patients. Skin grafts were performed for 21 patients, local or regional flaps for 14 patients, and free flaps for 6. Vacuum-assisted closure was selected for 8 patients. The wounds were successfully closed in all the patients. Two patients with upper-limb injuries had nonunion. Motor nerve injuries recovered in 7/10 patients. Due to hypergranulating tissue, 2 patients treated with vacuum-assisted closure (VAC) had to stop treatment early. Their wounds were closed with skin graft or local flap. The classic reconstructive ladder, starting from direct closure and ending with a free flap, should be extended for limb traumas and include acute shortening with or without angulation, followed by distraction osteogenesis and the VAC system on the same step as the free flap.

One hundred ninety eight adult patients who had sustained long bone fractures were treated by external fixation from admission to bone healing and consolidation. Of these, 135 had sustained high-energy injuries, 39 of them had suffered multi-system injuries. Superficial pin track infection was the most common complication, occurring predominantly in pins located in the femur, upper tibia and upper humerus. There were no cases of deep infection or osteomyelitis. One patient with a femoral shaft fracture developed a DVT although he was on preventive low molecular weight heparin, i.e. sc Clexane 40 mg daily. There were no cases of PE or ARDS. External fixation systems are a minimal invasive surgical modality, which allow three-dimensional fracture fixation after closed or minimal open reduction. They require a good command of surgical anatomy, but provide an optimal preservation of the fracture's soft tissue envelope, the critical biological factor for new bone formation and fracture healing. Recent publications have suggested that in the critically ill patient, minimally invasive fracture fixation surgery may prevent the perpetuation of a reactive, life threatening inflammatory reaction (the "second hit") which may induce the development of multiple organ dysfunction (MODS).

As we treat our 230th patient from the Syrian conflict, the pathology we see is more debilitating and the humanitarian needs of the wounded have become even more obvious. This case presents some graphic images of the realities of war. Care in the most advanced units cannot restore broken limbs, let alone broken lives. We present a case of a young war-injured man, who suffered severe crush injury to the pelvis and lower limb, arriving at our medical facility after a delay of hours. The lower limb was shattered from the pelvis down (essentially a traumatic hemipelvectomy). His life had been saved in Syria by ligation of the femoral vessels in an unknown facility by an unknown medical team. On arrival in a centre in Israel for definitive care of an unsalvageable leg, formal hemipelvectomy was performed.

Longitudinally extensive spinal cord lesions (LESCLs) are believed to occur predominantly with opticospinal multiple sclerosis (OSMS) and are associated with disability. The purpose of this study is to describe the prevalence and patterns of spinal cord lesions in Hispanics with multiple sclerosis (MS) and OSMS and their association with disability. A cross-sectional study of 164 patients with complete MRIs was used. In each case the spinal cord was classified: LESCLs, scattered spinal cord lesions (sSCLs) or no spinal cord lesions (noSCLs). Clinical course was defined as classical MS or OSMS. Risk of disability (Expanded Disability Status Scale ≥4.0) was adjusted for age, disease duration and sex using logistic regression. A total of 125/164 (73 %) MS patients had spinal cord lesions (sSCLs, 57 %; LESCLs, 19 %), but only 11 (7 %) had OSMS. LESCLs were associated with disability (p < 0.0001), longer disease duration (p < 0.0001) and MS (n = 21 vs. n = 10 OSMS; p < 0.0001). LESCLs were also associated with the greatest risk to disability (OR 7.3, 95 % CIs 1.9–26.5; p = 0.003; sSCLs OR 2.5, 95 % CIs 0.9–7.1; p = 0.09) compared with noSCLs. LESCLs are more common than OSMS and are associated with worse disability even in patients with MS. These results suggest that LESCLs are a more important marker of disability in MS than OSMS and may be an early indicator of more aggressive disease in this population.

Aim To describe computed tomography (CT) imaging and histopathological manifestations of renal epithelioid angiomyolipomas (EAMLs) for better understanding and cognition in the diagnosis of this new category of renal tumours. Materials and methods Clinical data and CT images from 10 cases of EAML were retrospectively analysed. All patients underwent CT with and without contrast medium administration, with multiplanar reconstruction (MPR) when needed. Results Plain CT manifestations of EAMLs were a higher density of mass (10–25 HU) than renal parenchyma, bulging contour of the involved kidney, absence of fat, distinct edges without a lobulate appearance. Contrast-enhanced CT features were markedly heterogeneous enhancement (from rapid wash-in to slow wash-out), large tumour size without lobular appearance, complete capsule with distinct margins and frequent mild necrotic areas. Histopathological features were epithelioid cells with eosinophilic cytoplasm, large and deeply stained nuclei, and dense arrangement of tumour cells with patchy necrosis; diffuse sheets of epithelioid cells were positive for HMB-45 (melanoma-associated antigen) and negative for epithelial membrane antigen (EMA) staining. Conclusion Multiple specific CT features correlated well with the histopathology and may play an important role in the primary diagnosis of EAMLs.

Multiple sclerosis (MS) is a demyelinating disease in the central nervous system. Genetics have been considered as a leading factor in the prevalence and disease course of MS. We have presented an informatics-based eFolder system for integrating patients' clinical data with MR images and lesion quantification results. The completed eFolder system has been designed and developed in aiding to evaluate disease manifestation differences in Hispanic and Caucasian MS patients. MS lesion data, as shown in MRI, can be extracted by the 3-D automatic lesion detection tool in the eFolder, and data storing and mining tools in eFolder is able to extract and compare data from individual patients. The computer-aided detection (CAD) algorithm has been modified and enhanced to include spatial information as detection criteria. For this study, 36 Caucasian MS patients and 36 matched Hispanic patients have been selected. Most recent MR images of the patients are collected, and images are evaluated both by the CAD tool in the eFolder and radiologists. The results are compared between Caucasian and Hispanic patients and statistically evaluated to see if the two populations have significant difference in lesion presentations. The results can be used to evaluate differences in the two groups of patients and to evaluate the new CAD algorithm's performance with radiologists' contours. Significant findings can further evaluate effectiveness of MS eFolder in MS-related research.

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. The chronic nature of MS necessitates multiple MRI studies to track disease progression. We have presented an imaging informatics decision-support system, called MS eFolder, designed to integrate patient clinical data with MR images and a computer-aided detection (CAD) component for automatic white matter lesion quantification. The purpose of the MS eFolder is to comprehensively present MS patient data for clinicians and radiologists, while providing a lesion quantification tool that can be objective and consistent for MS tracking in longitudinal studies. The MS CAD algorithm is based on the K-nearest neighbor (KNN) principles and has been integrated within the eFolder system. Currently, the system has been completed and the CAD algorithm for quantifying MS lesions has undergone the expert evaluation in order to validate system performance and accuracy. The evaluation methodology has been developed and the data has been collected, including over 100 MS MRI cases with various age and ethnic backgrounds. The preliminary results of the evaluation are expected to include sensitivity and specificity of lesion and non-lesion voxels in the white matter, the effectiveness of different probability thresholds for each voxel, and comparison between CAD quantification results and radiologists' manual readings. The results aim to show the effectiveness of a MS lesion CAD system to be used in a clinical setting, as well as a step closer to full clinical implementation of the eFolder system.

Conventional contrast-enhanced MR imaging is the current standard technique for the diagnosis and treatment evaluation of gliomas and other brain neoplasms. However, this method is quite limited in its ability to characterize the complex biology of gliomas and so there is a need to develop more quantitative imaging methods. Perfusion and permeability MR imaging are two such techniques that have shown promise in this regard. This review will highlight the underlying principles, applications, and pitfalls of these evolving advanced MRI methods.

An acceptable emergency fracture reduction fixation using a unilateral tubular external fixation frame often can be continued until bone healing is completed. However, unilateral external fixation, as a definitive method of skeletal stabilization in patients suffering from high-energy injuries, has been associated with a high rate of nonunion [10, 20, 37].

A 47-year-old man presented with dull pain in the left upper abdomen for 1 year. Computed tomograph (CT) examination revealed a very large heterogeneously enhancing mass in the left kidney, measuring up to 28 cm. The mass was accompanied by several enlarged lymph nodes in the peri-aortic region. Radical nephrectomy was performed and pathologic evaluation revealed sheets of epithelioid cells and piecemeal necrosis consistent with malignant epithelioid angiomyolipoma (EAML) with regional lymph node metastases. The tumor cells were strongly positive for human melanosome-associated protein (HMB-45) on immunohistochemical staining. There was neither metastasis nor recurrence 2 years postoperatively. EAML is a rare tumor of mesenchymal tissue with potential for aggressive behavior. If this neoplasm is suspected based on CT features, EAML should be confirmed by pathology and immunohistochemistry.

Background: The treatment of distal tibial osteomyelitis represents a challenge for orthopedic and plastic surgeons. The affected tissues should be debrided and good vascularized tissue should cover the defect, but the option of a muscle flap covering the area is limited. Free flaps are used but require longer operating time and experience with microsurgery, may result in donor-site morbidity, and sometimes add bulky tissue to the area. The authors present their experience with a sural musculoneurocutaneous flap for the treatment of chronic osteomyelitis of the distal tibia. Methods: Over a 2-year period, nine distally based sural musculoneurocutaneous flaps were used in the treatment of chronic osteomyelitis of the distal tibia. Four patients had comorbid conditions (smoking, diabetes mellitus, venous insufficiency, or obesity). The clinical aspect was represented by drainage sinuses located in the distal part of the tibia. Five patients had postsurgical scars on the lateral malleolar region and one had medial and lateral malleolar scarring. Three patients had an Ilizarov device at the time of wound coverage. Results: All wounds were closed successfully. Dehiscence surrounding the flap was encountered in a single case that was attributable to inadequate bone debridement; this flap was raised to allow extending the debridement, and a local medial fasciocutaneous flap completed wound coverage. Distal tip necrosis of the flap was encountered in two cases. Conclusions: The sural musculoneurocutaneous sural flap was successfully used for treatment of distal tibia osteomyelitis. Although it is believed that lateral malleolar scars might compromise the flap, the flaps in the authors' series survived. This flap can also be applied to patients with external fixators without removing the apparatus.

Ectopic pituitary adenomas are exceedingly rare entities that are often misdiagnosed. The resulting delay in diagnosis may be particularly concerning in the case of Cushing syndrome caused by an ectopic adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. Although the total resection of ectopic adenomas results in rapid and durable remission, persistent Cushing syndrome is often associated with permanently damaging invasive procedures and significantly higher risk of mortality. The authors report the case of a 48-year-old man with ACTH-dependent Cushing syndrome. On the morning before surgery, his serum cortisol measured 51 μg/dl, his ACTH level was 195.7 pg/ml, and his urinary free cortisol level was 2109 μg/day. Serum cortisol was not suppressed with the administration of high-dose dexamethasone. Imaging showed separate masses in both the sphenoid sinus and the pituitary gland, complicating the diagnostic process and requiring pathological assessment of both masses. No other abnormalities were found on thoracic, abdominal, or pelvic scans. Gross-total resection of both lesions was accomplished via an endoscopic endonasal transsphenoidal approach. Pathology confirmed an ectopic ACTH pituitary adenoma of the sphenoid sinus and a Crooke hyaline change of the pituitary gland. The patient achieved stable hormonal remission without significant postoperative complications, returned to full activity within 3 months, and remained disease free nearly 1 year after tumor resection. In a systematic literature review, the authors identified 41 cases of ectopic ACTH-secreting pituitary adenomas, including 18 arising in the sphenoid sinus without direct involvement of the sella. Including the case described here, the total number of ectopic ACTH pituitary adenomas arising in the sphenoid sinus was 19, and the total number of ectopic ACTH pituitary adenomas without regard to location was 42. For the 19 patients with adenomas found in the sphenoid sinus, ages ranged from 16 to 76 years, and there were 15 women and 4 men. The mean and median diameters of the resected sphenoid masses were 13.9 and 8 mm, respectively, with a range of 3–55 mm. Seven were microadenomas (< 1 cm). Fifteen of the 19 cases reported serum ACTH and morning cortisol levels, the means of which were 106.7 pg/ml and 32.5 μg/dl, respectively. Gross-total tumor resection was achieved in all patients except one, and in all of them durable hormonal remission of Cushing syndrome was achieved (mean follow-up time 20 months). Ectopic pituitary adenomas are rare but important causes of Cushing syndrome and related endocrinopathies, particularly because of the rapid onset and severity of symptoms with atypical presentation. Ectopic pituitary adenomas, especially those in the nasal cavity, nasopharynx, or paranasal sinuses, are easily misidentified. Any patient presenting with signs and symptoms of Cushing syndrome without any obvious pituitary adenoma or other sources of hypercortisolemia should be thoroughly screened for an ectopic adenoma. However, as with the case presented here, the coincident existence of a sellar mass should not preclude the possibility of an ectopic source. There should be a high degree of clinical suspicion for any mass in the general area surrounding the sella when evaluating Cushing syndrome.

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.

The soft tissues play a crucial part in both the stabilization of the multiple joint surfaces of the calcaneus and in allowing propulsion as needed. Therefore, minimally invasive functional stabilization of heel bone fracture is a promising technique, which may bypass all published controversies. Experience has shown that ligamentotaxis, which means the use of mechanical forces applied to the soft-tissue envelope of fractures without the surgical disruption of the latter, contributes to fracture healing and reconstruction. Therefore, based on our results, minimally invasive techniques are useful and promising in calcaneal fracture treatment.

We present our experience in the treatment of nonunited fractures of long bones in the presence of a retained fragment of the broken intramedullary nail. Of 287 long bone fractures treated by intramedullary fixation, we recalled 5 patients with broken intramedullary nails. In two patients the distal fragments of broken nails were not extracted and refixation was performed by an Ilizarov ring fixation with the broken piece left in situ. The patients ambulated with full weight bearing immediately following surgery. We achieved good results in both patients with fracture union times between 16 and 22 weeks. No complication was observed. Ring fixation using thin wires or half pins inserted beside fragments of the broken nail provides a simple and minimally traumatic method of treatment in patients when encountering difficulties extracting a retained fragment of broken intramedullary nails.

Because of their complexity, war injuries inflicted by a blast mechanism often require tailoring of treatment to attain a more individualized solution. We report two cases of bilateral, severely mangled lower limbs with open tibial fractures and crush injuries to the feet. In each case, one limb had to be amputated below the knee, but the other limb was saved by immediate stabilization in a tubular external fixation frame crossing the knee; the frame was later replaced by a hybrid ring fixation frame with a freely moving knee. Such incidences are rare, and the particular management detailed here has not previously been reported in the literature.