[The postoperative cervical spine and evaluation of the spinal cord with magnetic resonance tomography]

We present the cases of ten patients who underwent postoperative magnetic resonance assessment after dislocation injuries of the cervical spine and treatment with anterior interbody fusion and titanium implants. Eight patients had spinal cord injuries and two had nerve root disorders. In two patients who had intracranial haematomas and dislocation fractures of the cervical spine, MRI proved useful for identification of parenchymal spinal cord injuries as the reason for transverse lesions. Severe MR findings of the parenchymal spinal cord injuries (haematoma or transection) correlated with complete transverse lesions (4 patients) and oedema of the spinal cord, with incomplete transverse lesions (3 patients). MR enables us to examine the spinal cord after operations to ensure that correct spinal cord decompression has been achieved (3 patients). MRI is useful for detecting disc protrusion or chronic spinal stenosis in patients with titanium implants. All in all, MRI is an important modality in the evaluation of the posttraumatic cervical spine.

[Hyperextension injury of the lower cervical spine and diagnosis of dorsal unstable motion segments]

Five patients with hyperextension injuries and dorsally instable motion segments are presented. In the diagnosis of posterior instabilities plain roentgenograms demonstrated no characteristic signs of an injured cervical spine. Flexion and extension views detected a mild degree (2 mm) of retrospondylolisthesis in four cases and a widened disc space in one case. In all five patients the MR findings that made use suspect a posterior unstable motion segment were disc protrusions; in addition, in two patients these was hemorrhage in the spinal cord and in one patient cord edema.

Lack of pineal growth during childhood

During childhood, serum melatonin concentrations drop by approximately 80%, but the 24-h melatonin excretion is stable. Arrest of pineal growth after the end of infancy has been proposed as one possible mechanism underlying that phenomenon. To test this hypothesis, we reviewed 332 magnetic resonance imaging brain studies, classified as normal, of endocrine-normal children, aged 1 day to 15 yr, and estimated the pineal and pituitary sizes. The pineal was identified in 277 of 332 magnetic resonance imaging studies (83%). The average size (mean +/- SEM) of the pineal gland (transaxial diameter, 5.6 +/- 2.1; midsagittal diameter, 5.0 +/- 2.4; planimetric area, 28.5 +/- 17.8) did not differ with age. A total of 74 of 277 pineals with cysts (26.7%) were found. The occurrence of pineal cysts was equally distributed among the different age groups (chi 2 = 11.6; df = 14; P = 0.7). Ten pineals showed more than 1 cyst (3.6%). The pituitary was identified in 325 of 332 brain images (97.9%). The average pituitary size increased by some 100% from 1 to 15 yr of age [transaxial diameter: F = 2.2; P = 0.005 (by two-way analysis of variance); midsagittal diameter: F = 3.7; P = 0.0001; planimetric area: F = 7.1; P = 0.0001]. The pituitary was slightly larger in females than in males [midsagittal diameter: F = 8.8; P = 0.003 (by two-way analysis of variance); planimetric area: F = 7.9, P = 0.005]. The data presented indicate a lack of a discernible pineal growth after age 1 yr, which contrasts with pituitary development in the same individuals. The data are in agreement with a hypothesis suggesting a growth arrest of the pineal after infancy.

Radiolabeled octreotide for the demonstration of somatostatin receptors in malignant lymphoma and lymphadenopathy

This prospective study evaluated somatostatin receptor-specific scintigraphy as a clinical tool for routine detection of malignant lymphoma.

METHODS

Forty-one consecutive patients were examined using 111In-DTPA-D-Phe-1-octreotide. Thirty-four patients had diagnoses of Hodgkin's disease (n = 11) or non-Hodgkin's lymphoma (n = 23) previously verified and staged by hematology, histology and imaging methods (CT, chest x-ray and abdominal ultrasonography). The remaining seven patients initially suspected of presenting lymphoma (n = 5) or lymphoma recurrence after chemotherapy and radiotherapy (n = 2) were subsequently shown to have other diseases. Planar images were recorded 4, 24 and 48 hr after intravenous injection and evaluated without knowledge of other results. In case of negative planar scintigraphy, additional SPECT images were obtained. Since these failed to increase sensitivity, they were omitted after 15 negative recordings.

RESULTS

Octreotide scintigraphy did not yield false-positive results. The sensitivity for detecting Hodgkin's disease was 70% and varied from 88% in the neck and chest to 13% in the abdomen and pelvis. The sensitivity for non-Hodgkin's lymphoma was not influenced by localization and amounted uniformly to 35% but varied with the degree of malignancy between 44% (high-grade) and 29% (low-grade malignancy).

CONCLUSION

Our results suggest that radiolabeled octreotide is better suited to characterize somatostatin receptor expressing lymphomas than to localize lesion sites. It is useful for imaging Hodgkin's disease, especially above the diaphragm.

[Non-granulomatous prostatitis: MRI image with endorectal surface coil ("Endo-MRI")]

Inflammatory conditions of the prostate are often difficult to distinguish from early stages of prostate cancer with imaging techniques. The use of an endorectal surface coil in MRI of the prostate gland has been reported to provide superior resolution and better imaging of details than MRI with a body coil in the diagnosis of early prostate cancer. We report a 34-year-old patient with nonspecific non-granulomatous prostatitis in whom T2-weighted endorectal surface coil magnetic resonance imaging (ESCMRI) showed a region of markedly decreased signal intensity in the periphery of the gland. The low signal intensity of the lesion, its sharp demarcation from the normal part of the peripheral zone of the prostate and the marked bulge of the surface contour without capsular breach of the organ were interpreted as evidence of a bioptically proven benign inflammatory condition.

Follow-up and quality of survival of 67 consecutive children with CNS tumors

We report the findings at follow-up in 67 consecutive children with central nervous system tumors treated over a 5-year-period at a single institution. The diagnoses were supratentorial astrocytoma (n = 12), cerebellar astrocytoma (n = 10), ependymoma (n = 9), medulloblastoma (n = 9), brain stem glioma (n = 6), optic pathway glioma (n = 5), and others (n = 16). The survival rates were 83% for supratentorial astrocytomas at a median of 46.5 months, 90% for cerebellar astrocytomas and 55% for ependymomas at 40 months, respectively, 55% for medulloblastomas at 22 months, 33% for brain stem gliomas at 23 months, and 80% for optic pathway gliomas at 49 months. With regard to neurological sequelae, 13 patients were treated for epilepsy, 13 patients had mild to moderate neurological deficits, and 4 patients were severely disabled. Seventeen of 37 tested patients performed below average on formal neuropsychometric testing, one-fourth attended special education courses, and at least one-fourth suffered from behavioral and adjustment problems.

[Distinguishing of scar tissue from recurrent tumor after therapy of tumors of the female pelvis]

Patients treated for gynecological malignancies are followed up at short intervals during the first 3 years after treatment. Locoregional recurrence in the pelvis is often not detectable by palpation. Thus, efficient and sensitive follow-up of patients treated for gynecologic malignancies requires the use of imaging techniques. Computed tomography is well suited for the primary diagnoses of locoregional recurrences and lymph-node metastases after radical surgery. In addition to detailed anatomical information, magnetic resonance imaging (MRI) permits tissue characterization on the basis of signal intensity and thus differentiation between fibrosis and recurrence. After primary radiotherapy for cervical cancer, MRI follow-up can assess tumor response to treatment. Prognostic evaluation of the success or failure of treatment requires knowledge of the signal characteristics and volume of the primary tumor and of the interval since primary treatment. In our experience, conventional spin-echo sequences with heavy T2-weighting are best for distinguishing between fibrosis and recurrence.

The sphenoid sinus during childhood: establishment of normal developmental standards by MRI

To obtain baseline standards of normal age-related development of the sphenoid sinus during childhood magnetic resonance images of the sphenoid sinus in 401 patients less than 15 years old were reviewed. T1-weighted sagittal and T2-weighted axial scans were evaluated for bone marrow conversion, development of pneumatization, spatial enlargement and septation of the sphenoid sinus. The sphenoid sinus had a uniformly low signal intensity (red bone marrow) on T1-weighted images in all children less than 4 months old. Signal intensity changes from hypo- to hyperintense (bone marrow conversion) started at age of 4 months. Onset of pneumatization was observed in 12% of the patients at age 13-15 months. By age 43-48 months, 85% of the patients showed pneumatization of the anterior part of the sphenoid bone. Pneumatization was complete in all patients older than 10 years. Enlargement of the sinus showed a characteristic profile in each dimension. Median septation was observed irregularly with age, with a maximum of 77%. Septum variants were noticed between 4.5% and 20%. The recognition of this phenomenon may serve as a reference for evaluating normal and abnormal development of the sphenoid sinus and may be of great value for diagnostic and therapeutic management of pathologic conditions of the child's sphenoid sinus and its surrounds.

Magnetic resonance assessment of age-related development of the sphenoid sinus

Magnetic resonance images of the sphenoid sinus in 401 patients under 15 years old were reviewed to establish normal age-related standards. T1-weighted sagittal and T2-weighted axial scans were evaluated for bone marrow conversion, development of pneumatization, spatial enlargement and septation of the sphenoid sinus. The sphenoid sinus had a uniformly low signal intensity (red bone marrow) on T1-weighted images in all children less than 4 months old. Signal intensity changes from hypointense to hyperintense (bone marrow conversion) started at the age of 4 months. Onset of pneumatization was observed in 12% of the patients at age 13-15 months. By age 43-48 months, 85% of the patients showed pneumatization of the anterior part of the sphenoid bone. Pneumatization was complete in all patients older than 10 years. Enlargement of the sinus showed a characteristic profile in each dimension. Median septation was observed irregularly with age, with a maximum of 77%. Septum variants were noticed between 4.5% and 20%. Because paediatric sinus disease is a challenging problem in children, these results may be useful as baseline standards of normal age-related development of the sphenoid sinus during childhood.

Quantitative assessment of fracture healing. The value of computerised sonometry in a correlative animal experiment in sheep

Usually follow-up of the healing process of bone fractures is by subjective assessment of standard X-rays, based on the clinician's personal experience. It is therefore impossible to completely avoid misjudgements in the evaluation of the mechanical stability. Other authors have reported that the mechanical response of bony structures to a knock impulse allows a definitive statement about the stiffness of a fracture. The practicability of computerised sonometry in computer-aided evaluation of the mechanical vibration reaction and the acoustic transmission of sound through osseous structures for assessing stability has been proved in experimental and clinical studies. We designed an animal study that would allow a systematic correlation between the diagnostic investigations in general use. As a main goal, this study tries to correlate sonography with other quantitative techniques, even if they are not used under everyday clinical conditions. Our results show that methods based on direct assessment of the mechanical stability between fracture fragments allow a more exact evaluation of fracture healing. This study helps to classify the results of computerised sonometry together with other diagnostic procedures used for the evaluation of fracture healing, and furthermore provides a basis for clinical interpretation of the findings of a new, non-invasive technique for precise quantitative assessment of fracture healing.

Ultrasound diagnosis of birth-related spinal cord trauma: neonatal diagnosis and follow-up and correlation with MRI

Two neonates, one with complete and one with incomplete birth-related transection of the cervico-thoracic spinal cord, form the basis of this report. Ultrasound and MRI findings in primary diagnosis and follow-up are described. The aim of this contribution is to bring this serious birth complication to the attention of the reader, to present the obstetrical risk factors, to describe the clinical presentation of the newborns and to make suggestions to expand the field of indications for spinal sonography. The value of spinal ultrasound in the first six months of life is stressed, especially in comparison to MRI. For definitive assessment of the lesion (transectional or nontransectional) follow-up ultrasound studies for several weeks are required.

[Radiologic diagnosis of Perthes disease]

In Legg-Calvé-Perthes disease (LCPD), magnetic resonance imaging (MRI) and conventional radiography in two planes are considered the most important methods of investigation for early diagnosis and for assessment of the course of the disease. MRI can reveal the early marrow oedema, thus allowing early differential diagnosis against diseases that are similar in clinical appearance (coxitis fugax, epiphyseal dysplasia). The extent of the necrotic area within the epiphysis, the most important indicator of the prognosis of the disease and thus for the therapeutic management, can be assessed earlier and more reliably with MRI than with other techniques. The loss of containment can be visualized by MRI, because depiction of the cartilaginous structures is possible earlier than with conventional radiography. Staging of LCPD is also possible with MRI, especially in stages I and II. Radiography shows the reossification and the osseous remodelling of the epiphysis better. A disadvantage of MRI seems to be the occasional need for sedation or anaesthesia of the child to avoid motion artefacts.

Undifferentiated (embryonal) sarcoma of the liver in childhood. Successful combined-modality therapy in four patients

BACKGROUND

Undifferentiated (embryonal) sarcoma of the liver is a rare, highly malignant, mesenchymal tumor presenting predominantly in late childhood. Four girls, ages 6-13 years, who were treated with combined-modality regimens are reported.

METHODS

In the first and second patients, hemihepatectomy resulted in complete removal of the tumor, and multiple-agent chemotherapy was administered postoperatively. In the third patient, only partial resection could be accomplished initially. By synchronous radiation therapy and chemotherapy, the tumor decreased to an extent that it could be resected completely and was totally devitalized on histologic examination. Postoperative chemotherapy was discontinued after 8 weeks. In the fourth patient, the tumor was not resectable at diagnostic biopsy. Polychemotherapy led to a significant reduction of the tumor size, and resection with clear margins could be performed subsequently. Because histologic necrosis amounted to about 95%, postoperative chemotherapy was also discontinued after 6 weeks.

RESULTS

All four patients remain well without evidence of tumor recurrence after 79, 41, 36, and 22 months from diagnosis.

CONCLUSIONS

The authors suggest that a multimodal therapeutic regimen should be used in patients with undifferentiated hepatic sarcoma.

MR findings and treatment of four patients with cervical spinal cord injuries

We report the value of magnetic resonance imaging (MRI) in the assessment of cervical spine injuries with neurological deficit and the implications such information might have in the management of acute spinal cord injuries. Four cases are presented that were neurologically classified according to the 5-step Frankel scale. Three patients presented with an intramedullary hemorrhage. One of these patients showed additional mild compression of the spinal cord due to a retropulsed bony fragment, and one an epidural hematoma without any evidence of spinal cord compression. The fourth patient had compression of the spinal cord secondary to bony fragments from a burst fracture. We carried out two decompressions of the spinal cord by removing the disc and bony fragments. In addition, we performed two interbody fusions. In one patient we applied a halo vest, and in one case surgical intervention was not necessary after MRI assessment.

Cervical cord compression in hereditary multiple exostoses

A seven year old girl, known to have hereditary multiple exostoses, developed moderate gait disorders at the age of six years. Deterioration of myelopathy initiated the clinical investigation including spinal computed tomography (CT) and magnetic resonance imaging (MRI). These examinations demonstrated a coneshaped exostosis originating from the posterior arch of C2. The spinal canal was markedly narrowed with significant compression of the spinal cord at the C2 level. The girl underwent laminectomy of C2 with total removal of the exostosis. Postoperative deterioration of neurological symptoms correlated with a hypointense lesion on T1 weighted imaging in the cord at the same level, but no further cord compression on follow-up MRI. The spastic tetraparesis has improved considerably within 12 months thereafter.

Ultrasound and MRI findings in a case of childhood amyloid goiter

Goiter secondary to amyloidosis is rare in clinical practice and only a few descriptions of its radiologic features have been reported. We present the ultrasound and MRI findings of thyroid amyloidosis in a 7-year-old Turkish boy with familial Mediterranean fever.

[The value of magnetic resonance tomography in diagnosis and follow-up of cervical spine injuries]

We report upon 12 cases of magnetic resonance imaging of cervical spinal cord injuries, in 8 cases done within 24 h after the injury. We found haemorrhages in the spinal cord in 3 cases, compression of the spinal cord in 3, swelling of the spinal cord in 2, and transsection of the spinal cord and hematoma in the epidural space in 1 case each. A normal MR image was seen in a patient with a complete transverse lesion of the spinal cord. The other 4 MR examinations were carried out between 2 weeks and 8 months after injury or operation. In 2 of these trauma victims interbody fusion of the cervical spine was performed, and the neurological deficit was subsequently worse in both. In 1 patient the course of a haemorrhage within the spinal cord was monitored by MR imaging: 1 image revealed the treatment of a burst fracture of C-7 with an interposed flap from the greater omentum.