Lucas Giansante Abud

Flow Reversal Versus Filter Protection A Pilot Carotid Artery Stenting Randomized Trial

Background—Carotid artery stenting (CAS) has become an alternative treatment for patients presenting symptomatic carotid artery stenosis. The improvement in clinical outcomes with CAS has been associated with the development of embolic protection devices. The trial aim is to compare flow reversal versus filter protection during CAS through femoral access. Methods and Results—Patients were randomly enrolled in CAS using flow reversal or filter protection. The primary end points were the incidence, number, and size of new ischemic brain lesions after CAS. The secondary end points included major adverse cardiac and cerebrovascular events, transient ischemic attack, and definitive ischemic brain lesions on fluid-attenuated inversion recovery magnetic resonance image at a 3-month follow-up. Ischemic brain lesions were assessed by a 3T magnetic resonance image. Neurological outcomes were evaluated by means of the National Institutes of Health Stroke Scale and the modified Rankin Scale (mRS). Forty consecutive patients were randomly assigned. Compared with flow reversal (n=21), filter protection (n=19) resulted in a significant reduction in the incidence (15.8% versus 47.6%, P=0.03), number (0.73 versus 2.6, P=0.05), and size (0.81 versus 2.23 mm, P=0.05) of new ischemic brain lesions. Two patients, 1 from each group, presented transient ischemic attack at 3-month follow-up. There were no major adverse cardiac and cerebrovascular events in the hospital or at 3-month follow-up. Conclusions—In this small sample size trial, filter protection was more effective than flow reversal in reducing ischemic brain lesions during CAS through femoral approach. Clinical Trial Registration—URL: http://portal2.saude.gov.br/sisnep/. Unique identifier: 0538.0.004.000-10.

Linfoma Burkitt-símile cerebral mimetizando cisto coloide intraventricular

1. Department of Radiology and Imaging Diagnosis, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, RS, Brazil. Mailing address: Dr. Felipe Welter Langer. Department of Radiology and Imaging Diagnosis, University Hospital of Santa Maria, Federal University of Santa Maria. Avenida Roraima, 1000, Camobi. Santa Maria, RS, Brazil, 97105900. E-mail: felipewlanger@gmail.com. with high local invasion, rapid growth, and early distant metastasis unless they are excised in a timely manner. The most common locations for MPNST in neurofibromatosis patients are the extremities, head, and neck. Thoracic involvement, however, is remarkably rare, few cases having been reported. According to the size and location of the intrathoracic tumor, compressive manifestations such as pain, dyspnea, dysphagia, and superior vena cava syndrome may be the presenting manifestations, as seen in our patient, who reported dyspnea as the sole symptom related to his MPNST. The identification of MPNST in neurofibromatosis patients may be troublesome for several reasons. First, the existence of multiple benign neurofibromas may delay the identification of changes in plexiform neurofibromas. In addition, because superficial cutaneous neurofibromas do not undergo malignant transformation, MPNSTs often remain undetected until they reach a moderate size or cause compressive symptoms. Furthermore, CT and magnetic resonance imaging might not be accurate enough to differentiate benign from malignant lesions with any degree of reliability in the very early stages, although advances have been made in the area of positron emission tomography. Therefore, any suspicious lesions should generally prompt histological sampling. Although the mainstay of successful treatment of an MPNST is surgical excision after disease staging, neoadjuvant chemotherapy may be employed in order to reduce its dimensions beforehand, especially in patients with lesions surrounding vital organs. Radiotherapy might also delay recurrence, although it has not been shown to improve survival in MPNST patients. REFERENCES

Síndrome inflamatória da reconstituição imune e criptococose neuropulmonar em paciente HIV-negativo

Radiol Bras. 2016 Nov/Dez;49(6):406–413 411 http://dx.doi.org/10.1590/0100-3984.2015.0200 The differential diagnoses include other diseases affecting the trachea, not only those presenting localized involvement— such as primary tracheal neoplasms, injuries of traumatic origin, and some infectious diseases—but also those presenting diffuse involvement—amyloidosis, tracheobronchopathia osteochondroplastica, relapsing polychondritis, laryngotracheobronchial papillomatosis, tracheobronchomegaly, neurofibromatosis, Wegener’s granulomatosis, lymphoma, and paracoccidioidomycosis. Imaging studies have become increasingly important in the evaluation of chest diseases, as recently noted in the radiology literature of Brazil. In the study of the trachea, imaging studies comprise X-rays and, primarily, CT of the chest, which can show irregular, circumferential narrowing of the lumen, with or without mediastinitis. In fibrotic disease, the lumen is smoother and the wall is not thickened. Lymphadenopathy is generally associated with active tuberculosis. Bronchoscopy can reveal inflamed mucosa, submucosal granuloma or polyp, ulceration, hypertrophy, or cicatricial stenosis; histologically, tracheobronchial tuberculosis can be identified the presence of giant cell granuloma and caseous necrosis. Although the gold standard for the diagnosis of tracheobronchial tuberculosis is the finding of granulomas in the tracheal/bronchial mucosa, a diagnosis based on imaging findings and sputum positivity is accepted and enables immediate treatment. Making a diagnosis of tracheobronchial tuberculosis requires suspicion, and it is necessary to correlate the clinical manifestations with the radiological findings. Early diagnosis and treatment can avert the complications of the disease.

Radiological findings in megaesophagus secondary to Chagas disease: chest X-ray and esophagogram

Objective To identify and classify the radiographic patterns of megaesophagus in Chagas disease, as seen on esophagograms and chest X-rays. Materials and Methods This was a prospective study of 35 patients diagnosed with esophageal disease via manometry. The changes found on esophagograms were stratified according to Rezendes classification, divided into four categories (grades I through IV) determined by the degree of dilatation and impairement of esophageal motility. We subsequently correlated that ranking with the chest X-ray findings: gastric air bubble; air-fluid level; and mediastinal widening. Results Among the 35 patients, the esophageal disease was classified as grade I in 9 (25.7%), grade II in 3 (8.6%), grade III in 19 (54.3%), and grade IV in 4 (11.4%). None of the patients with grade I esophageal disease showed changes on chest X-rays. In two of the three patients with grade II disease, there was no gastric air-bubble, although there were no other findings in any of the grade II patients. Of the 19 patients with grade III disease, 15 had abnormal findings on X-rays. All four patients with grade IV disease showed abnormalities. Conclusion The use of Rezendes classification is feasible, encompassing findings ranging from the subtle changes that characterize the initial phases of esophageal disease to the complete akinesia seen in dolicomegaesophagus. Chest X-ray findings are more common in patients with advanced stages of the disease and indicate the degree of esophageal involvement in Chagas disease.

Concomitant pulmonary and central nervous system paracoccidioidomycosis with cerebellar abscess

A 59-year-old man with no previous diagnosis was admitted to hospital with a history of headache, ataxia, and cough. Computed tomography (CT) of the chest showed groundglass attenuation, consolidation, nodules, cavitations, and fi brotic lesions in both lungs, strongly suggesting the possibility of a granulomatous process (Figure A). These radiological fi ndings are commonly seen in fungal disease, supporting a diagnosis of a chronic form of pulmonary paracoccidioidomycosis(1). The contrast-enhanced coronal T1-weighted magnetic resonance image (MRI) of the brain showed a ring-enhancing mass in the left cerebellar hemisphere, suggesting a necrotic lesion (Figure B). A hypersignal in the cavity on the axial diffusion-weighted image (Figure C) was interpreted as reduced water molecule movement (restricted diffusion) and refl ected a high viscosity of the proteinaceous fl uid with a high concentration of infl ammatory cells. Although these features are not pathognomonic, they are extremely characteristic of an abscess(2). The patient underwent surgical drainage of the cerebellar lesion. The histopathological findings were leveduriform structures of Paracoccidioides brasiliensis. Paracoccidioidomycosis (PCM) is one of the most common fungal diseases and can compromise one or multiple organs(3). Diagnosis can be confi rmed by biopsy, immunological assay, culture, or direct microscopy. Recommended pharmacological treatment includes itraconazole, sulfamethoxazole + trimethoprim, and amphotericin B. Thus, the combination of chest CT fi ndings, suggesting a granulomatous infectious process, and MRI, showing a probable encephalic abscess, should lead to a diagnosis of PCM with concomitant involvement of the central nervous system and lungs, allowing early initiation of specifi c treatment and reduction of the associated morbimortality.

Acute dengue encephalitis in a female Brazilian adult

A 65-year-old female resident of Ribeirão Preto, São Paulo, Brazil, presented with a 4-day history of a headache, fever, myalgia, mild dyspnea, painful respiration, and vomiting. After 4 days, her condition worsened with a loss of muscle tone, seizures, and a decreased level of consciousness. Physical examination showed Babinski sign bilaterally. A computed tomography scan performed on day 7 showed minimal hypodensity of the internal capsule. Her serum electrolyte and creatinine levels were normal. Two analyses of cerebrospinal fluid showed: total protein of 72-86mg/dL; leukocyte count of 1.0/mm3; glucose level of 77-91mg/dL, and a chloride level of 118-125mg/dL. immunoglobulin M (IgM) and immunoglobulin G (IgG) test results for dengue were positive, whereas venereal disease research laboratory, cytomegalovirus, toxoplasmosis, and rubella serology test results were negative. Brain magnetic resonance imaging (MRI) on day 8 revealed small areas of hyperintensity on T2/Fluid attenuation inversion recovery (FLAIR)/, bilaterally, on both the internal capsule and corona radiata (Figure A) with minimal signs of diffusion restriction of water on the apparent diffusion coefficient map (Figure B). The susceptibility weighted imaging showed no signs suggestive of bleeding. The features observed in the imaging studies together with the clinical presentation and laboratory tests were consistent with those likely to be found in acute dengue encephalitis1-3. Complementary investigations ruled out other possible causes of neurological disorders1-3. After supportive therapy in the ICU, the patient improved and subsequently discharged. A posterior brain MRI revealed a regression of the signal intensity abnormalities seen previously and signs of cerebral volume loss (Figure C).

Cysticerci located in the fourth ventricle causing obstructive hydrocephalus: a radiological emergency requiring prompt diagnosis

[1]. Divisão de Neurorradiologia, Documenta Hospital São Francisco, Ribeirão Preto, São Paulo, Brasil. [2]. Divisão de Neurorradiologia, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil. [3]. Divisão de Neurorradiologia, MED Hospital São Lucas, Ribeirão Preto, São Paulo, Brasil. [4]. Divisão de Neurocirurgia, Hospital Santa Casa, Ribeirão Preto, São Paulo, Brasil. [5]. Divisão de Radiologia, Universidade Federal de São Paulo, São Paulo, São Paulo, Brasil.

Anterior cerebral artery aneurysm rupture presenting as hemorrhage in the splenium of the corpus callosum

1. Hospital Universitário de Santa Maria (HUSM) – Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brazil. Mailing address: Dr. Felipe Welter Langer. Departamento de Radiologia e Diagnóstico por Imagem, Hospital Universitário de Santa Maria – Universidade Federal de Santa Maria. Santa Maria, RS, Brazil, 97105-900. E-mail: felipewlanger@gmail.com. restricted diffusion. There is typically no gadolinium enhancement. After glycemic correction, similarly to the clinical findings, such regions tend to return to normal signal intensity. It is important to highlight the role of susceptibility-weighted imaging (SWI) in differentiating between changes seen in HCHB and areas of calcification or hemorrhage, which represent the most common differential diagnoses. Calcium and blood deposits both generally manifest as hyperintensities on T1-weighted images with corresponding hypointensities on T2*-weighted images and SWI; conversely, HCHB changes tend to present as unilateral hyperintensities on T1-weighted images with no matching changes on T2*-weighted images or SWI.

Partial epilepsy: A pictorial review of 3 TESLA magnetic resonance imaging features

Epilepsy is a disease with serious consequences for patients and society. In many cases seizures are sufficiently disabling to justify surgical evaluation. In this context, Magnetic Resonance Imaging (MRI) is one of the most valuable tools for the preoperative localization of epileptogenic foci. Because these lesions show a large variety of presentations (including subtle imaging characteristics), their analysis requires careful and systematic interpretation of MRI data. Several studies have shown that 3 Tesla (T) MRI provides a better image quality than 1.5 T MRI regarding the detection and characterization of structural lesions, indicating that high-field-strength imaging should be considered for patients with intractable epilepsy who might benefit from surgery. Likewise, advanced MRI postprocessing and quantitative analysis techniques such as thickness and volume measurements of cortical gray matter have emerged and in the near future, these techniques will routinely enable more precise evaluations of such patients. Finally, the familiarity with radiologic findings of the potential epileptogenic substrates in association with combined use of higher field strengths (3 T, 7 T, and greater) and new quantitative analytical post-processing techniques will lead to improvements regarding the clinical imaging of these patients. We present a pictorial review of the major pathologies related to partial epilepsy, highlighting the key findings of 3 T MRI.

Microcephaly caused by congenital Zika virus infection and viral detection in maternal urine during pregnancy

Currently Latin America is undergoing a major epidemic of Zika virus, which is transmitted by Aedes mosquitoes. Concern for Zika virus infection has been increasing as it is suspected of causing brain defects in newborns such as microcephaly and, more recently, potential neurological and autoimmune complications including Guillian-Barré syndrome and acute disseminated encephalomyelitis. We describe a case of virus infection in a 25-year-old woman during the first trimester of her pregnancy, confirmed by laboratory tests only for the detection of viral particles in maternal urine, with imaging studies demonstrating the progression of cranial and encephalic changes in the fetus and later in the newborn, such as head circumference reduction, cerebral calcifications and ventriculomegaly.