CT and MRI Evaluation of Bilateral Enlarged Vestibular Aqueduct Syndrome with Curved Reconstructions – A Case Report and Short Review of Literature

Enlarged Vestibular Aqueduct Syndrome (EVAS) is a known, but rare entity. It represents a common cause of congenital sensorineural hearing loss, diagnosed more often in children with a slight female predominance. Herein, we report a case of bilateral Enlarged Vestibular Aqueduct Syndrome [EVAS] in a 26-year-old male. As it is a subtle finding on imaging, the interpreting radiologist must be aware of this entity to make the diagnosis. The diagnostic CT and MRI images of this patient are given along with curved CT and MRI reconstructions along the plane of the Vestibular Aqueduct [VA] extending to the endolymphatic sac [ES]. The CT reconstructions demonstrate the bony anatomy in great detail and the bilateral dilated VA. These help in excluding diseases like otospongiosis and inner ear anomalies. The curved MRI reconstruction CISS images through the VA demonstrate the entire endolymph channel. The reconstructed MRI Images clearly demonstrate a patent endolymph channel without any focal abnormality such as stricture, or other associated congenital anomalies.

A needs assessment of pediatric epilepsy surgery in Haiti

OBJECTIVEEpilepsy disproportionately affects low- and/or middle-income countries (LMICs). Surgical treatments for epilepsy are potentially curative and cost-effective and may improve quality of life and reduce social stigmas. In the current study, the authors estimate the potential need for a surgical epilepsy program in Haiti by applying contemporary epilepsy surgery referral guidelines to a population of children assessed at the Clinique d’Épilepsie de Port-au-Prince (CLIDEP).METHODSThe authors reviewed 812 pediatric patient records from the CLIDEP, the only pediatric epilepsy referral center in Haiti. Clinical covariates and seizure outcomes were extracted from digitized charts. Electroencephalography (EEG) and neuroimaging reports were further analyzed to determine the prevalence of focal epilepsy or surgically amenable syndromes and to assess the lesional causes of epilepsy in Haiti. Lastly, the toolsforepilepsy instrument was applied to determine the proportion of patients who met the criteria for epilepsy surgery referral.RESULTSTwo-thirds of the patients at CLIDEP (543/812) were determined to have epilepsy based on clinical and diagnostic evaluations. Most of them (82%, 444/543) had been evaluated with interictal EEG, 88% of whom (391/444) had abnormal findings. The most common finding was a unilateral focal abnormality (32%, 125/391). Neuroimaging, a prerequisite for applying the epilepsy surgery referral criteria, had been performed in only 58 patients in the entire CLIDEP cohort, 39 of whom were eventually diagnosed with epilepsy. Two-thirds (26/39) of those patients had abnormal findings on neuroimaging. Most patients (55%, 18/33) assessed with the toolsforepilepsy application met the criteria for epilepsy surgery referral.CONCLUSIONSThe authors’ findings suggest that many children with epilepsy in Haiti could benefit from being evaluated at a center with the capacity to perform basic brain imaging and neurosurgical treatments.

Jejunal Lesion Identified at a Previous Anastomosis Site in a Dog Using Capsule Endoscopy

ABSTRACT A 3 yr old spayed female French bulldog was evaluated for a progressive regenerative anemia of unknown origin that was unresponsive to empiric immunosuppressive and gastroprotective therapy. The patient had a history of previous resection and anastomosis of a small intestinal diverticulum ∼2 yr prior to evaluation for her anemia. Capsule endoscopy revealed a focal abnormality in the distal jejunum at the site of a previous bowel resection and anastomosis. This lesion was suspected to be the cause of ongoing gastrointestinal bleeding and anemia. Exploratory laparotomy combined with endoscopy was performed to further investigate and localize the jejunal lesion. The lesion was resected, and a primary end-to-end jejunal anastomosis was performed. Histopathology of the specimen revealed jejunal suture granulomas with focal ulceration. The patient recovered well from surgery with significant improvement of the anemia and resolution of clinical signs at recheck examinations 1 and 2 wk postoperatively. Complete resolution of the anemia was noted at a 6 wk follow-up. The case report demonstrates how, in cases of unknown causes of anemia, capsule endoscopy is a noninvasive method of identifying the presence of gastrointestinal bleeding as a result of lesions that might otherwise not be detectable with abdominal ultrasound or conventional endoscopy. The report also documents a long-term complication to a resection and anastomosis surgery.

Expert radiologists have improved memory performance for images with focal abnormalities

Memory capacity depends on prior knowledge, both in working memory and in long-term memory. For example, radiologists have improved long-term memory for medical images compared to novices. Furthermore, people tend to remember abnormal or surprising items best. This is often claimed to arise primarily because such items attract additional attention at encoding. How do expertise and abnormality interact when experts are actively searching for abnormalities; e.g. radiologists looking at mammograms? In the current work, we investigate whether expert radiologists (N=32) show improved memory performance for abnormal images compared to novice participants (N=60). We consider two types of “abnormality.” A mammogram can have a focal abnormality that can be localized or it could simply be the mammogram of a woman known to have cancer (e.g. the image of the breast contralateral to the focal abnormality). Must an image have a focal abnormality for additional attentional processing to be engaged? We found that experts have better memory for mammograms than novice participants and enhanced memory for abnormal images relative to normal images. Overall, radiologists showed no memory benefit for the contralateral-abnormal images and did not discriminate them from normal images, but had enhanced memory for images with focal abnormalities. Our results suggest that focal abnormalities play an important role in enhancing memory of expert observers.

Galactorrhoea following Acupuncture

A 41-year-old woman with breast cancer was referred to the pain management clinic for a course of acupuncture for intense pain following a subcutaneous mastectomy and a latissimus dorsi flap reconstruction. She was treated with a standard course of acupuncture for breast pain, using paravertebral segmental points, trigger points, plus contralateral LI4 on the non-lymphoedematous arm. She experienced an episode of galactorrhoea six days following the first treatment and during the second treatment. She had not previously lactated for four years. CT and MRI of the brain revealed no focal abnormality. Acupuncture has been used in to promote lactation in the Traditional Chinese literature using the ‘Tianzong’ acupoint SI11. This acupoint coincided with a trigger point over infraspinatus that was included in the neurophysiologically based acupuncture treatment. Quantitative analysis has shown an increase in the production of prolactin and oxytocin following acupuncture. These hormones are involved in the synthesis and release of milk from mammary glands respectively. This is the first report of galactorrhoea, in the contralateral normal breast, following acupuncture in a patient with breast cancer.

Convulsive Status Epilepticus in Children with Intractable Epilepsy is Frequently Focal in Origin

Background:Convulsive status epilepticus (CSE) is a common neurological emergency. Our objectives were to study children with recurrent nonfebrile CSE to assess the evidence for focal origin.Methods:Series of 18 children with recurrent CSE and intractable epilepsy were identified by chart review. Clinical, radiological, and EEG data were reviewed. Focal structural abnormalities were identified on MRI and CT images by one neuroradiologist who was unaware of the clinical details.Results:The patient's ages ranged between 6-22 years (mean 15.3, SD 4), and 67% were males. Most children (89%) had a severe cognitive and / or behavioural disorder. Most patients (89%) had multiple seizure types and 95% of these were partial seizures. Twelve (67%) children had at least one episode of CSE with focal features identified clinically. Focal brain abnormalities were detected on 18% and 55% of CTand MRI films respectively. Overall, 53% had a focal abnormality on structural neuroimaging. Interictal EEG revealed focal or multifocal abnormalities on at least one occasion in 94% and 22% of patients respectively. Overall, 17 patients had focal features on at least one EEG. Thirteen ictal EEGs were recorded on 11 (61%) patients. Ten (91%) of these recordings revealed a focal onset.Conclusions:Many handicapped children with recurrent CSE have focal clinical, radiological, or electrographic features. This supports a focal origin for CSE in most children with intractable epilepsy.

Segmental Spinal Dysgenesis

Segmental spinal dysgenesis is characterized by focal agenesis or dysgenesis of the lumbar or thoracolumbar spine, with focal abnormality of the underlying spinal cord and nerve roots. Children are symptomatic at birth with lower limb deformities and neurological deficits that may be segmental. Myelography and computed tomography disclose hypoplastic or absent vertebrae and atrophic or absent neural elements adjacent to the bony deformity; the spinal column distal to the abnormality may be partially bifid, but is otherwise normal. Spinal ultrasonography was a helpful diagnostic adjunct in one patient. Surgery may be helpful in decompressing partially functioning spinal cord or nerve roots, but may exaggerate the tendency toward spinal instability. The embryology of this abnormality is not clear, but two children had other anomalies suggesting a spinal dysraphic syndrome, and its cause is probably related to a segmental maldevelopment of the neural tube.