I-Chan Chiang

Distinction between pyogenic brain abscess and necrotic brain tumour using 3-tesla MR spectroscopy, diffusion and perfusion imaging

The purpose of this study is to compare the effectiveness of relative cerebral blood volume, apparent diffusion coefficient and spectroscopic imaging in differentiating between cerebral abscesses and necrotic tumours. In the prospective study, a 3-tesla MR unit was used to perform proton MR spectroscopy, diffusion and perfusion imaging in 20 patients with cerebral abscesses and 26 patients who had solitary brain tumours (14 high-grade gliomas and 12 metastases). We found the mean apparent diffusion coefficient value at the central cavities of the cerebral abscesses to be significantly lower than in necrotic tumours. The mean relative cerebral blood volume values of the necrotic tumour wall were statistically significantly higher than the mean relative cerebral blood volume values of the cerebral abscess wall by the Students t-test. The proton spectra obtained revealed amino acids only in the cerebral abscesses. Although the conventional MRI characteristics of cerebral abscesses and necrotic tumours may sometimes be similar, diffusion, perfusion-weighted and spectroscopic MRI enables distinction between the two.

Splenic Abscesses: Review of 29 Cases

Splenic abscess is an unusual and potentially life‐threatening disease. Due to the nonspecific clinical picture, it remains a diagnostic challenge. Splenic abscess should be suspected in febrile patients with left upper quadrant tenderness and leukocytosis, and diagnosis confirmed based mostly on imaging studies, microbiologic and/or pathologic evidence, or by response to antibiotic or antifungal treatment. We present 29 cases of splenic abscess treated in our hospital from 1990 to 2001. There were 18 male patients (62%) and 11 female patients (38%). Ages ranged from 4 to 85 years, with a median of 44 years. There were five pediatric patients (17%) and 24 adults (83%). The most common associated condition was leukemia. Most patients were immunocompromised (72%). The more common signs and symptoms were fever (90%), chills (41%), abdominal pain (31%), and leukocytosis (38%). Ultrasonography of the abdominal cavity was positive in 27 cases (93%); computerized tomography or magnetic resonance imaging was used in 26 patients (90%) and was positive in all patients. The abscess was solitary in 21 cases (72%) and multiple in eight cases (28%). Positive blood cultures were found in only seven patients (24%). According to the literature, the treatment of choice is still splenectomy, but in our study, the success rate of 75% with antibiotics alone indicates that antibiotic therapy should be considered an important alternative treatment modality in patients not suitable for percutaneous drainage and splenectomy.

Homocysteine Levels;MTHFR C677T Genotype;and MRI Hyperintensities in Late-onset Major Depressive Disorder

OBJECTIVE Epidemiological studies suggest that elevated plasma homocysteine is associated with an increased risk of depression and cerebrovascular disease. There are no published reports of homocysteine levels and methylenetetrahydrofolate reductase (MTHFR) C677T genotype in clinical samples of patients with late-onset major depressive disorder (MDD). The purpose of this study was to examine the association of homocysteine levels or MTHFR C677T genotype and late-onset MDD and assess whether this may be affected by brain magnetic resonance imaging (MRI) hyperintensities. METHODS Authors recruited 39 elderly patients with MDD with first episode occurring after age 50 and 20 comparison subjects and assessed total plasma homocysteine levels, MTHFR genotype, and brain MRIs. RESULTS Plasma total homocysteine levels were higher in elderly patients with late-onset MDD versus comparison subjects. The association did not change after controlling for MRI hyperintensities, and the distribution of MTHFR C677T genotype was not different between the groups. CONCLUSIONS In this exploratory study, elevated homocysteine levels were associated with late-onset MDD, and the association did not appear to be mediated by vascular pathology as identified by brain MRI hyperintensities.

Proton magnetic resonance spectroscopy of late-life major depressive disorder

The primary goal of this study was to examine the biochemical abnormalities of late-life major depression by using 3-tesla (3-T) proton magnetic resonance spectroscopy ((1)H-MRS). The antidepressant effects on the biochemical abnormalities were investigated as well. Study participants were 27 elderly patients with major depressive disorders (among which 9 were on antidepressant medication) and 19 comparison elderly subjects. (1)H-MRS spectra were acquired from voxels that were placed in the left frontal white matter, left periventricular white matter, and left basal ganglia. Ratios of N-acetylaspartate (NAA), choline (Cho) and myo-inositol to creatine were calculated. Patients with late-life major depressive disorder had a significantly lower NAA/creatine ratio in the left frontal white matter, and higher Cho/creatine and myo-inositol/creatine ratios in the left basal ganglia when compared with the control subjects. The myo-inositol correlated with global cognitive function among the patients. The biochemical abnormalities in late-life major depressive disorder were found on the left side of the frontal white matter and the basal ganglia. Neuron degeneration in the frontal white matter and second messenger system dysfunction or glial dysfunction in the basal ganglia are suggested to be associated with late-life depression.

Structural Abnormality on Brain Magnetic Resonance Imaging in Late-Onset Major Depressive Disorder

The purpose of this study was to examine the structural abnormalities of patients with late‐onset major depressive disorder using brain magnetic resonance imaging (MRI) and to assess clinical correlates of these structural abnormalities. Thirty‐seven elderly patients with DSM‐IV major depressive disorder that first occurred after the age of 50 years, and 18 control subjects without depression were recruited. All participants underwent comprehensive psychiatric assessment and cerebral MRI. Brain ventricular and sulcal sizes and white matter hyperintensities were assessed visually. Relative to control subjects, patients with late‐life major depressive disorder showed more severe brain atrophy (p = 0.043) and white matter hyperintensities (p = 0.024), especially in the periventricular area (p = 0.012). Over 60% of the patient group had significant brain MRI hyperintensities. White matter hyperintensity was correlated with later onset of depressive illness (r = 0.49, p = 0.002) among patients. Brain atrophy and white matter hyperintensities are prevalent in patients with late‐onset major depressive disorders. These two abnormalities may represent different pathophysiologic processes of depressive disorders. White matter hyperintensities may be predisposing factors for late‐onset major depressive disorder.

Exogenous Lipoid Pneumonia: Serial Chest Plain Roentgenography and High-Resolution Computerized Tomography Findings

Between May 1988 and July 2002, six patients with pneumonia due to diesel, animal, or vegetable oil aspiration were admitted to Kaohsiung Medical University Hospital. The purpose of this study was to demonstrate distinctive radiographic findings of oil‐induced lipoid pneumonitis on initial serial chest roentgenograms and high‐resolution computerized tomography (CT) scans. Initial chest roentgenograms (n = 6), CT scans (n = 6), and roentgenography and CT follow‐up studies were analyzed retrospectively by two chest radiologists and two surgeons, focusing on the pattern and distribution of parenchymal abnormalities. The most common location was the right middle lobe, followed by the right lower lobe, the left lower lobe, and the lingular lobe. Follow‐up chest roentgenograms (n = 6) showed complete disappearance of the parenchymal lesions in only one patient and partial decrease in the extent of lesions in five patients. Lipoid pneumonia presents non‐specific findings on chest roentgenography. It is commonly located in both lower and the right middle lobes. On high‐resolution CT, the lesions appear most commonly as areas of consolidation, ground‐glass attenuation mixed with paving pattern, and poorly defined nodules.

Follow-up for covered stent treatment of carotid blow-out syndrome in patients with head and neck cancer

OBJECTIVE Carotid blow-out syndrome (CBS) is a life-threatening complication of head and neck cancer (HNC). One of the various methods used for emergency management of CBS is covered stent placement (CSP). Our initial experience in CSP is evaluated and compared with reports in the literature. METHODS This study analysed 17 patients with HNC who had received CSP for CBS at Kaohsiung Medical University Chung-Ho Memorial Hospital from May 2005 to December 2013. The medical records and images for these patients were retrospectively reviewed to evaluate the causes of CBS, treatment success rates and complications. RESULTS The initial angiography success rate was 100%. Procedural or periprocedural complications were noted in two (12%) cases, both suffering from cerebral vascular accident (CVA). Short-term complications were noted in eight (47%) cases, including four rebleeding cases and four CVA cases. Medium- to long-term complications were noted in nine cases, which included two asymptomatic in-stent thrombosis cases, one symptomatic CVA case, two abscess formation cases and four rebleeding cases. Overall, eight (47%) cases of rebleeding occurred during follow-up. Three of the eight cases were fatal, accounting for 27% of the all-cause mortality. CONCLUSION Although CSP is considered effective for achieving haemostasis in patients with HNC with CBS, the medium- to long-term outcomes are unfavourable owing to high risks of rebleeding, CVA and other complications. Therefore, CSP should be considered a temporary life-saving technique rather than a definitive treatment. ADVANCES IN KNOWLEDGE Analysis of the relatively large series of patients with HNC in this study suggests that CSP is a useful temporary treatment for CBS.

Spontaneous retroperitoneal biloma: a case report.

We report a rare case of spontaneous rupture of the biliary tree with biloma in the retroperitoneum. A 74-year-old man was admitted with back pain and general weakness. Computerized tomography (CT) and sonography showed a huge lesion in the right retroperitoneum, and a diagnosis of biloma was made after percutaneous aspiration. A percutaneous drainage catheter was initially inserted into the right retroperitoneal lesion under sonographic guidance to treat the biloma because of high surgical risk. When his general condition had improved, the patient underwent cholecystectomy and removal of the common bile duct stone; there was no evidence of leakage in the extrahepatic bile duct. Non-surgical intervention before definitive biliary surgery is considered the first choice for treating bilomas in high-risk patients.

Endovascular therapy in the emergent management of intractable hemorrhage associated with head and neck neoplasms

PurposeTo evaluate the feasibility, safety, and efficacy of endovascular interventions in the emergent management of life-threatening hemorrhage associated with head and neck neoplasm.Materials and methodsOver the past 5 years, 4 patients were subjected to emergent angiography to identify the sources of intractable bleeding and to endovascular interventions in an attempt to stop bleeding and salvage patient life. Selective bilateral CCA, ICA, and ECA arteriographies were initiated to document the underlying pathology and transcatheter arterial embolization with various embolic agents and stent deployment were carried out for cessation of intractable bleeding.ResultsThe overall technical success rate is 75% (3/4). Two patients with buccal carcinoma were successfully treated with gelatin sponge pledgets and polyvinyl alcohol particles embolizations. One patient with a bulky ruptured RICA pseudoaneurysm associated with neurofibromatosis was successfully embolized with a 2–4 mm fibered platinum coil. The remaining patient with a wide-neck LCCA pseudoaneurysm resulted from IAIC for left buccal carcinoma was treated with two superimposing Easy Wallstents in the distal LCCA-LICA followed by 10 platinum coils embolizations due to non-availability of stent-graft (Covered stent). Unfortunately, despite sluggish flow leading to the pseudoaneurysm appreciated on fluoroscopy, the fragile pseudoaneurysm ruptured approximately 8 minutes thereafter while waiting for complete thrombosis. With the stents in place at LCCA-LICA, the vascular surgeon was able to ligate the LCCA and LICA to exclude the psendoaneurysm. No complications were encountered in all patients.ConclusionEndovascular therapy with various embolic agents and stent deployments were feasible, safe, and efficacious in the acute management of intractable hemorrhage associated with head and neck neoplasms.