Multiple Abdominal abscesses following ventriculoperitoneal shunt placement in an immunosuppressed patient: An illustrative case

Background

Ventriculoperitoneal (VP) shunt placement is one of the most performed procedures in neurosurgery to treat various types of hydrocephalus (HC). Immediate or late postoperative complications may quite commonly occur, especially in immunosuppressed patients, who are predisposed to develop rare and difficult-to-treat conditions.

Case Description

Herein, we report the case of a 41-year-old female patient with a prior history of acute myeloid leukemia, followed by a tetra-ventricular acute HC due to a spontaneous non-aneurysmal subarachnoid hemorrhage. After an urgent external ventricular drainage placement, she underwent careful testing of "shunt dependency," which ended with a VP shunt placement. After 2 months, she presented at the emergency department with worsening abdominal pain and fever. She underwent a computed tomography scan with contrast administration, which has shown abscesses in the abdominal cavity. An urgent surgical revision of the VP shunt and antibiotics administration followed this. After inflammatory markers normalization, due to the high risk of post-infective peritoneal adherence and consequent impairment of cerebrospinal fluid absorption, a ventriculoatrial shunt was considered the most appropriate solution.

Conclusion

Abdominal abscesses are a rare but subtle complication after VP shunt placement. Their management depends on etiology, patient clinical characteristics, and manifestations. Prompt interventions have been shown to improve clinical outcomes and optimize quality of life in such delicate patients.

Gadolinium-Doped Carbon Nanodots as Potential Anticancer Tools for Multimodal Image-Guided Photothermal Therapy and Tumor Monitoring

This study focuses on the synthesis and characterization of gadolinium-doped carbon nanodots (CDs-Gd) and their potential applications in multimodal imaging and precision cancer therapy. CDs-Gd were synthesized through a solvothermal decomposition method combining citric acid, GdCl3, and urea. The incorporation of Gd3+ ions within the carbonaceous structure resulted in stable CDs-Gd with a peculiar architecture that retained optical and paramagnetic properties. Combined characterization techniques confirmed the presence of pH-sensitive COOH functions on the CDs-Gd surface along with the unique lattice structure induced by Gd3+ doping. The optical properties of CDs-Gd exhibited a tunable emission spectrum displaying blue-green emission with pH-dependent behavior. Additionally, CDs-Gd exhibited contrast-enhancing properties in T1-weighted magnetic resonance imaging (MRI) experiments. MRI acquisitions at different Gd3+ concentrations and pH values demonstrated the potential of CDs-Gd as contrast agents for monitoring pH changes in an aqueous environment. We found that the relaxivity of CDs-Gd at pH 5.5 (tumor, 11.3 mM-1 s-1) is roughly 3-fold higher than that observed at pH 7.4 (physiological, 5.0 mM-1 s-1) and outperformed clinical standards such as γ-butyrol (3.3 mM-1 s-1). Monitoring pH changes in tumor microenvironment (TME) is crucial for evaluating the effectiveness of anticancer treatments and understanding tumor progression. Furthermore, CDs-Gd demonstrated concentration-dependent photothermal conversion ability in the near-infrared (NIR) region, allowing for efficient heat generation under laser irradiation. This indicates the potential application of CDs-Gd in image-guided photothermal therapy (IG-PTT) for cancer treatment. The in vitro studies on MCF-7 (breast cancer) and 16-HBE (healthy bronchial epithelium) cell lines demonstrated that CDs-Gd exhibited high biocompatibility (cell viability >80%). However, upon NIR activation, they showed potent anticancer effects by inhibiting tumor cell proliferation and inducing apoptosis selectively in cancer cells. In conclusion, the synthesized CDs-Gd nanoparticles possess unique optical, photothermal, and MRI contrast properties, making them promising candidates for multimodal imaging-guided precision cancer therapy applications.

Improvement of neutron sensitivity for lithium formate EPR dosemeters: a Monte Carlo analysis

This work presents the computational analysis of the sensitivity improvements that could be achieved in lithium formate monohydrate (LFM) electron paramagnetic resonance (EPR) dosemeters exposed to neutron beams. Monte Carlo (MC) simulations were performed on LFM pellets exposed to neutron beams with different energy spectra at various depths inside a water phantom. Various computations were carried out by considering different enrichments of 6Li inside the LFM matrix as well as addition of different amounts of gadolinium oxide inside the pellet blend. The energy released per unit mass was calculated with the aim of predicting the increase in dose achievable by the addition of sensitizers inside the pellets. As expected, a larger amount of 6Li induces an increase of energy released because of the charged secondary particles (i.e. 3H ions and α-particles) produced after neutron capture. For small depths in water phantom and low-energy neutron spectra the dose increase due to 6Li enrichment is high (more than three orders of magnitude with respect to the case of with 7Li). In case of epithermal neutron beams the energy released in 6Li-enriched LFM compound is smaller but larger than in the case of fast neutron beams. On the other hand, the computational analysis evidenced that gadolinium is less effective than 6Li in improving neutron sensitivity of the LFM pellets. Discussion based on the features of MC transport code is provided. This result suggests that 6Li enrichment of LFM dosemeters would be more effective for neutron sensitivity improvement and these EPR dosemeters could be tested for dosimetric applications in Neutron Capture Therapy.

MR-guided focused ultrasound-induced blood-brain barrier opening for brain metastasis: a review

Although the therapeutic armamentarium for brain metastases (BMs) has been expanded from innovative surgical techniques and radiotherapy to include targeted therapies and immunotherapy, the prognosis of BMs remains poor. Despite the proven efficacy of numerous compounds in preclinical studies, the limited penetration of promising therapeutic agents across the blood-brain barrier (BBB) remains an unaddressed issue. Recently, low-intensity magnetic resonance-guided focused ultrasound (MRgFUS) in combination with microbubbles has been shown to overcome vascular and cellular transport barriers in the brain and tumor microenvironment, resulting in increased drug diffusion and preliminary effective results. Preclinical studies have investigated the increased penetration of many therapeutic agents including doxorubicin, trastuzumab, and ipilimumab into the CNS with promising results. Furthermore, anticancer drugs combined with MRgFUS-induced BBB opening have been demonstrated to improve animal survival and slow tumor progression. Accordingly, the first clinical trial has recently been launched and hopefully the results will provide evidence for the safety and efficacy of drug delivery enhanced by MRgFUS-induced BBB opening in BMs. This review aims to provide an overview of transcranial low-intensity MRgFUS application for BBB disruption and a comprehensive overview of the most relevant evidence in the treatment of BMs.

COVID-19 and neurological disorders: what might connect Parkinson's disease to SARS-CoV-2 infection

SARS-CoV-2 infection leading to Coronavirus disease 19 (COVID-19) rapidly became a worldwide health emergency due to its elevated infecting capacity, morbidity, and mortality. Parkinson’s disease (PD) is the second most common neurodegenerative disorder and, nowadays the relationship between SARS-CoV-2 outbreak and PD reached a great interest. Apparently independent one from the other, both diseases share some pathogenetic and clinical features. The relationship between SARS-CoV-2 infection and PD is complex and it depends on the direction of the association that is which of the two diseases comes first. Some evidence suggests that SARS-CoV-2 infection might be a possible risk factor for PD wherein the exposure to SARS-CoV-2 increase the risk for PD. This perspective comes out from the increasing cases of parkinsonism following COVID-19 and also from the anatomical structures affected in both COVID-19 and early PD such as olfactory bulb and gastrointestinal tract resulting in the same symptoms such as hyposmia and constipation. Furthermore, there are many reported cases of patients who developed hypokinetic extrapyramidal syndrome following SARS-CoV-2 infection although these would resemble a post-encephalitic conditions and there are to date relevant data to support the hypothesis that SARS-CoV-2 infection is a risk factor for the development of PD. Future large, longitudinal and population-based studies are needed to better assess whether the risk of developing PD after COVID-19 exists given the short time span from the starting of pandemic. Indeed, this brief time-window does not allow the precise estimation of the incidence and prevalence of PD after pandemic when compared with pre-pandemic era. If the association between SARS-CoV-2 infection and PD pathogenesis is actually putative, on the other hand, vulnerable PD patients may have a greater risk to develop COVID-19 being also more prone to develop a more aggressive disease course. Furthermore, PD patients with PD showed a worsening of motor and non-motor symptoms during COVID-19 outbreak due to both infection and social restriction. As well, the worries related to the risk of being infected should not be neglected. Here we summarize the current knowledge emerging about the epidemiological, pathogenetic and clinical relationship between SARS-CoV-2 infection and PD.

Epicardial and thoracic subcutaneous fat texture analysis in patients undergoing cardiac CT

Introduction

The aim of our study was to evaluate the feasibility of texture analysis of epicardial fat (EF) and thoracic subcutaneous fat (TSF) in patients undergoing cardiac CT (CCT).

Materials and methods

We compared a consecutive population of 30 patients with BMI ≤25 kg/m² (Group A, 60.6 ± 13.7 years) with a control population of 30 patients with BMI >25 kg/m² (Group B, 63.3 ± 11 years). A dedicated computer application for quantification of EF and a texture analysis application for the study of EF and TSF were employed.

Results

The volume of EF was higher in group B (mean 116.1 cm³ vs. 86.3 cm³, p = 0.014), despite no differences were found neither in terms of mean density (-69.5 ± 5 HU vs. -68 ± 5 HU, p = 0.28), nor in terms of quartiles distribution (Q1, p = 0.83; Q2, p = 0.22, Q3, p = 0.83, Q4, p = 0.34). The discriminating parameters of the histogram class were mean (p = 0.02), 0,1st (p = 0.001), 10_th (p = 0.002), and 50_th percentiles (p = 0.02). DifVarnc was the discriminating parameter of the co-occurrence matrix class (p = 0.007).The TSF thickness was 15 ± 6 mm in group A and 19.5 ± 5 mm in group B (p = 0.003). The TSF had a mean density of -97 ± 19 HU in group A and -95.8 ± 19 HU in group B (p = 0.75). The discriminating parameters of texture analysis were 10_th (p = 0.03), 50_th (p = 0.01), 90_th percentiles (p = 0.04), S(0,1)SumAverg (p = 0.02), S(1,-1)SumOfSqs (p = 0.02), S(3,0)Contrast (p = 0.03), S(3,0)SumAverg (p = 0.02), S(4,0)SumAverg (p = 0.04), Horzl_RLNonUni (p = 0.02), and Vertl_LngREmph (p = 0.0005).

Conclusions

Texture analysis provides distinctive radiomic parameters of EF and TSF. EF and TSF had different radiomic features as the BMI varies.

Microchimerism in multiple sclerosis: The association between sex of offspring and MRI features in women with multiple sclerosis

Aims

During pregnancy, fetal cells can migrate to the mother via blood circulation. A percentage of these cells survive in maternal tissues for decades generating a population of fetal microchimeric cells (fMCs), whose biological role is unclear. The aim of this study was to investigate the association between the sex of offspring, an indirect marker of fMCs, and magnetic resonance imaging (MRI) features in women with multiple sclerosis (MS).

Methods

We recruited 26 nulliparous MS patients (NPp), 20 patients with at least one male son (XYp), and 8 patients with only daughters (XXp). Each patient underwent brain MR scan to acquire 3D-T2w FLAIR FatSat and 3D-T1w FSPGR/TFE. Lesion Segmentation Tool (LST) and FreeSurfer were used to obtain quantitative data from MRI. Additional data were collected using medical records. Multiple regression models were applied to evaluate the association between sex of offspring and MS data.

Results

Comparing NPp and XXp, we found that NPp had larger 4th ventricle volume (2.02 ± 0.59 vs. 1.70 ± 0.41; p = 0.022), smaller left entorhinal volume (0.55 ± 0.17 vs. 0.68 ± 0.25; p = 0.028), and lower thickness in the following cortical areas: left paracentral (2.34 ± 0.16 vs. 2.39 ± 0.17; p = 0.043), left precuneus (2.27 ± 0.11 vs. 2.34 ± 0.16; p = 0.046), right lateral occipital (2.14 ± 0.11 vs. 2.25 ± 0.08; p = 0.006). NPp also had lower thickness in left paracentral cortex (2.34 ± 0.16 vs. 2.46 ± 0.17; p = 0.004), left precalcarine cortex (1.64 ± 0.14 vs. 1.72 ± 0.12; p = 0.041), and right paracentral cortex (2.34 ± 0.17 vs. 2.42 ± 0.14; p = 0.015) when compared to XYp. Comparing XYp and XXp, we found that XYp had higher thickness in left cuneus (1.80 ± 0.14 vs. 1.93 ± 0.10; p = 0.042) and left pericalcarine areas (1.59 ± 0.19 vs. 1.72 ± 0.12; p = 0.032) and lower thickness in right lateral occipital cortex (2.25 ± 0.08 vs. 2.18 ± 0.13; p = 0.027).

Discussion

Our findings suggested an association between the sex of offspring and brain atrophy. Considering the sex of offspring as an indirect marker of fMCs, we speculated that fMCs could accumulate in different brain areas modulating MS neuropathological processes.

Modulation of Human Motor Cortical Excitability and Plasticity by Opuntia Ficus Indica Fruit Consumption: Evidence from a Preliminary Study through Non-Invasive Brain Stimulation

Indicaxanthin (IX) from Opuntia Ficus Indica (OFI) has been shown to exert numerous biological effects both in vitro and in vivo, such as antioxidant, anti-inflammatory, neuro-modulatory activity in rodent models. Our goal was to investigate the eventual neuro-active role of orally assumed fruits containing high levels of IX at nutritionally-relevant amounts in healthy subjects, exploring cortical excitability and plasticity in the human motor cortex (M1). To this purpose, we applied paired-pulse transcranial magnetic stimulation and anodal transcranial direct current stimulation (a-tDCS) in basal conditions and followed the consumption of yellow cactus pear fruits containing IX or white cactus pear fruits devoid of IX (placebo). Furthermore, resting state-functional MRI (rs-fMRI) preliminary acquisitions were performed before and after consumption of the same number of yellow fruits. Our data revealed that the consumption of IX-containing fruits could specifically activate intracortical excitatory circuits, differently from the placebo-controlled group. Furthermore, we found that following the ingestion of IX-containing fruits, elevated network activity of glutamatergic intracortical circuits can homeostatically be restored to baseline levels following a-tDCS stimulation. No significant differences were observed through rs-fMRI acquisitions. These outcomes suggest that IX from OFI increases intracortical excitability of M1 and leads to homeostatic cortical plasticity responses.

Conventional MRI-Derived Biomarkers of Adult-Type Diffuse Glioma Molecular Subtypes: A Comprehensive Review

The introduction of molecular criteria into the classification of diffuse gliomas has added interesting practical implications to glioma management. This has created a new clinical need for correlating imaging characteristics with glioma genotypes, also known as radiogenomics or imaging genomics. Although many studies have primarily focused on the use of advanced magnetic resonance imaging (MRI) techniques for radiogenomics purposes, conventional MRI sequences remain the reference point in the study and characterization of brain tumors. A summary of the conventional imaging features of glioma molecular subtypes should be useful as a tool for daily diagnostic brain tumor management. Hence, this article aims to summarize the conventional MRI features of glioma molecular subtypes in light of the recent literature.

New frontiers in liver ultrasound: From mono to multi parametricity

Modern liver ultrasonography (US) has become a “one-stop shop” able to provide not only anatomic and morphologic but also functional information about vascularity, stiffness and other various liver tissue properties. Modern US techniques allow a quantitative assessment of various liver diseases. US scanning is no more limited to the visualized plane, but three-dimensional, volumetric acquisition and consequent post-processing are also possible. Further, US scan can be consistently merged and visualized in real time with Computed Tomography and Magnetic Resonance Imaging examinations. Effective and safe microbubble-based contrast agents allow a real time, dynamic study of contrast kinetic for the detection and characterization of focal liver lesions. Ultrasound can be used to guide loco-regional treatment of liver malignancies and to assess tumoral response either to interventional procedures or medical therapies. Microbubbles may also carry and deliver drugs under ultrasound exposure. US plays a crucial role in diagnosing, treating and monitoring focal and diffuse liver disease. On the basis of personal experience and literature data, this paper is aimed to review the main topics involving recent advances in the field of liver ultrasound.

Deep Learning Network for Segmentation of the Prostate Gland With Median Lobe Enlargement in T2-weighted MR Images: Comparison With Manual Segmentation Method

PURPOSE

Aim of this study was to evaluate a fully automated deep learning network named Efficient Neural Network (ENet) for segmentation of prostate gland with median lobe enlargement compared to manual segmentation.

MATERIALS AND METHODS

One-hundred-three patients with median lobe enlargement on prostate MRI were retrospectively included. Ellipsoid formula, manual segmentation and automatic segmentation were used for prostate volume estimation using T2 weighted MRI images. ENet was used for automatic segmentation; it is a deep learning network developed for fast inference and high accuracy in augmented reality and automotive scenarios. Student t-test was performed to compare prostate volumes obtained with ellipsoid formula, manual segmentation, and automated segmentation. To provide an evaluation of the similarity or difference to manual segmentation, sensitivity, positive predictive value (PPV), dice similarity coefficient (DSC), volume overlap error (VOE), and volumetric difference (VD) were calculated.

RESULTS

Differences between prostate volume obtained from ellipsoid formula versus manual segmentation and versus automatic segmentation were statistically significant (P < 0.049318 and P < 0.034305, respectively), while no statistical difference was found between volume obtained from manual versus automatic segmentation (P = 0.438045). The performance of ENet versus manual segmentations was good providing a sensitivity of 93.51%, a PPV of 87.93%, a DSC of 90.38%, a VOE of 17.32% and a VD of 6.85%.

CONCLUSION

The presence of median lobe enlargement may lead to MRI volume overestimation when using the ellipsoid formula so that a segmentation method is recommended. ENet volume estimation showed great accuracy in evaluation of prostate volume similar to that of manual segmentation.

Is Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound a Repeatable Treatment Option? Case Report of a Retreated Patient With Tremor Combined With Parkinsonism

INTRODUCTION

In recent years, transcranial Magnetic Resonance Imaging-guided Focused Ultrasound (tcMRgFUS) treatments for functional neurological disorders are giving a new thrust to the field of therapeutic brain lesioning.

OBJECTIVE

To present the case of a patient affected by tremor combined with Parkinsonism who underwent a second tcMRgFUS thalamotomy because of relapsing tremor after a few months from the first tcMRgFUS treatment.

METHODS

A 72-yr-old, right-handed man, came to our observation because of a disabling tremor affecting his upper limbs, refusing any invasive surgical procedure and already treated by tcMRgFUS left Vim thalamotomy. However, clinical benefit had brief duration, as a progressive recurrence of tremor on the right upper limb was observed after a few months from the first treatment. Thus, the patient underwent a new left-sided tcMRgFUS procedure 6 mo after the former treatment.

RESULTS

After the second procedure, an immediate and complete relief from tremor on the right upper limb was achieved with clinical benefit that persisted up to a 6-mo follow-up.

CONCLUSION

Since tcMRgFUS doesn't use ionizing radiations and it is incision-less, repeated and staged treatment procedures have always been hypothesized. Our report suggests that tcMRgFUS retreatment might actually be a feasible, safe, and effective option in selected patients in whom an optimal clinical outcome is not achieved after the first treatment session. However, future well-designed studies in large samples are needed to assess the possible risks of retreatment and the optimal timing of reintervention as well as eligibility and exclusion criteria.

Imaging of Substantia Nigra in Parkinson's Disease: A Narrative Review

Parkinson's disease (PD) is a progressive neurodegenerative disorder, characterized by motor and non-motor symptoms due to the degeneration of the pars compacta of the substantia nigra (SNc) with dopaminergic denervation of the striatum. Although the diagnosis of PD is principally based on a clinical assessment, great efforts have been expended over the past two decades to evaluate reliable biomarkers for PD. Among these biomarkers, magnetic resonance imaging (MRI)-based biomarkers may play a key role. Conventional MRI sequences are considered by many in the field to have low sensitivity, while advanced pulse sequences and ultra-high-field MRI techniques have brought many advantages, particularly regarding the study of brainstem and subcortical structures. Nowadays, nigrosome imaging, neuromelanine-sensitive sequences, iron-sensitive sequences, and advanced diffusion weighted imaging techniques afford new insights to the non-invasive study of the SNc. The use of these imaging methods, alone or in combination, may also help to discriminate PD patients from control patients, in addition to discriminating atypical parkinsonian syndromes (PS). A total of 92 articles were identified from an extensive review of the literature on PubMed in order to ascertain the-state-of-the-art of MRI techniques, as applied to the study of SNc in PD patients, as well as their potential future applications as imaging biomarkers of disease. Whilst none of these MRI-imaging biomarkers could be successfully validated for routine clinical practice, in achieving high levels of accuracy and reproducibility in the diagnosis of PD, a multimodal MRI-PD protocol may assist neuroradiologists and clinicians in the early and differential diagnosis of a wide spectrum of neurodegenerative disorders.

Human Spheroids from Adipose-Derived Stem Cells Induce Calvarial Bone Production in a Xenogeneic Rabbit Model

ABSTRACT

Calvarial defects can result from several causes. Tissue engineering hold the potential to restore native form and protective function. We have recently shown that stemness and differentiation ability of spheroids from adipose-derived stem cells (S-ASCs) promotes osteoblasts growth within Integra in a small vertebral lesion. In our study, we aimed to test osteogenic potential of S-ASCs in aiding regeneration of a calvarial defect. Groups containing Integra showed increased bone regeneration at the calvarial defect-Integra interface compared with the control group. In particular, S-ASC-derived osteoblasts group showed a superior calvarial remodeling than undifferentiated S-ASCs group. Clusters of ossification were observed in these both groups with enhanced microvasculature density and fibrosis. In conclusion, seeding of S-ASCs in dermal regeneration templates enhanced bone healing in a rabbit calvarial defect model. These findings could prompt the elective use of S-ASCs with enhanced multilineage differentiation potential for tissue engineering purposes.

Brain Mapping-Aided SupraTotal Resection (SpTR) of Brain Tumors: The Role of Brain Connectivity

Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.

Radiomics and Prostate MRI: Current Role and Future Applications

Multiparametric prostate magnetic resonance imaging (mpMRI) is widely used as a triage test for men at a risk of prostate cancer. However, the traditional role of mpMRI was confined to prostate cancer staging. Radiomics is the quantitative extraction and analysis of minable data from medical images; it is emerging as a promising tool to detect and categorize prostate lesions. In this paper we review the role of radiomics applied to prostate mpMRI in detection and localization of prostate cancer, prediction of Gleason score and PI-RADS classification, prediction of extracapsular extension and of biochemical recurrence. We also provide a future perspective of artificial intelligence (machine learning and deep learning) applied to the field of prostate cancer.

Neuroanatomical changes in early Parkinson's disease with mild cognitive impairment: a VBM study; the Parkinson's Disease Cognitive Impairment Study (PaCoS)

INTRODUCTION

Mild cognitive impairment (MCI) is common in Parkinson's disease (PD), but the underlying pathological mechanism has not been fully understood. Voxel-based morphometry could be used to evaluate regional atrophy and its relationship with cognitive performances in early PD-MCI.

PATIENTS AND METHODS

One hundred and six patients with PD were recruited from a larger cohort of patients, the Parkinson's Disease Cognitive Impairment Study (PaCoS). Subject underwent a T1-3D MRI and a complete clinical and neuropsychological evaluation. Patients were divided into PD with normal cognition (PD-NC) and PD-MCI according to the MDS level II criteria-modified for PD-MCI. A subgroup of early patients with short disease duration (≤ 2 years) was also identified. VBM analysis between PD-NC and PD-MCI and between early PD-NC and PD-MCI was performed using two-sample t tests with whole-brain statistical threshold of p < 0.001 uncorrected in the entire PD group and p < 0.05 FWE inside ROIs, in the early PD.

RESULTS

Forty patients were diagnosed with MCI and 66 were PD-NC. PD-MCI patients showed significant gray matter (GM) reduction in several brain regions, including frontal gyrus, precuneus, angular gyrus, temporal lobe, and cerebellum. Early PD-MCI showed reduction in GM density in superior frontal gyrus and cerebellum. Moreover, correlation analysis between neuropsychological performances and GM volume of early PD-MCI patients showed associations between performances of Raven and superior frontal gyrus volume, Stroop time and inferior frontal gyrus volume, accuracy of Barrage and volume of precuneus.

CONCLUSION

The detection of frontal and cerebellar atrophy, even at an early stage, could be used as an early marker of PD-related cognitive impairment.

Focused Ultrasound in Neuroscience. State of the Art and Future Perspectives

Transcranial MR-guided Focused ultrasound (tcMRgFUS) is a surgical procedure that adopts focused ultrasounds beam towards a specific therapeutic target through the intact skull. The convergence of focused ultrasound beams onto the target produces tissue effects through released energy. Regarding neurosurgical applications, tcMRgFUS has been successfully adopted as a non-invasive procedure for ablative purposes such as thalamotomy, pallidotomy, and subthalamotomy for movement disorders. Several studies confirmed the effectiveness of tcMRgFUS in the treatment of several neurological conditions, ranging from motor disorders to psychiatric disorders. Moreover, using low-frequencies tcMRgFUS systems temporarily disrupts the blood-brain barrier, making this procedure suitable in neuro-oncology and neurodegenerative disease for controlled drug delivery. Nowadays, tcMRgFUS represents one of the most promising and fascinating technologies in neuroscience. Since it is an emerging technology, tcMRgFUS is still the subject of countless disparate studies, even if its effectiveness has been already proven in many experimental and therapeutic fields. Therefore, although many studies have been carried out, many others are still needed to increase the degree of knowledge of the innumerable potentials of tcMRgFUS and thus expand the future fields of application of this technology.

MR-guided focused ultrasound application for moving target tumor ablation in abdominal area: coil selection

BACKGROUND

Magnetic Resonance Imaging (MRI)-guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive thermal ablation method utilizing high-intensity focused ultrasound (HI-FU) energy for tissue ablation under MRI with real-time thermal mapping. Ablating to a dynamic target as in the liver is very challenging, requiring approval. A novel quality-assured liver tumor ablation system has been proposed for clinics. The paper reports the evaluation of conventional and new MR-receiving coils.

PURPOSE

To evaluate the suitability of MR coils as part of the MRgFUS treatment system for liver, while simulating breathing motion in pre-clinical settings.

MATERIAL AND METHODS

The novel software communicates with the MR scanner and the transducer. To monitor the temperature via proton resonance frequency (PRF) methodology echo planar imaging (EPI) sequence was used while the algorithms of static, static and dynamic tracking were tested with sonications of 100 W for 30 s on tissue-mimicking phantoms. Different coil sets were used to assess the performance of the system for fitness for dynamic thermometry. Finally, in vivo experiments were performed over a porcine model.

RESULTS

Single-loop four-channel Duoflex and Gem coils provided adequate signal-to-noise ratio and contrast with consistent thermal readings. Body array coils showed severe loss of signal in dynamic cases since the integration of tracking algorithm causes low efficiency.

CONCLUSION

Body array coils are unsuitable for MRgFUS of the liver due to signal loss. The dedicated coil set with a single loop around the FUS transducer combined with four-channel arrays might be the best option for liver treatment using dynamic MRgFUS applications.

Broad neurodevelopmental features and cortical anomalies associated with a novel de novo KMT2A variant in Wiedemann-Steiner syndrome

Wiedemann-Steiner syndrome (WDSTS) is a rare genetic disorder including developmental delay/intellectual disability (DD/ID), hypertrichosis cubiti, short stature, and distinctive facial features, caused by mutation in KMT2A gene, which encodes a histone methyltransferase (H3K4) that regulates chromatin-mediated transcription. Different neurodevelopmental phenotypes have been described within the WDSTS spectrum, including a peculiar Autism Spectrum Disorder (ASDs) subtype in some affected individuals. Here, we report a 9-year-old Caucasian male found by next-generation panel sequencing to carry a novel heterozygous de novo KMT2A frameshift variant (NM_001197104.2:c.4433delG; p. Arg1478LeufsTer108). This boy presented a WDSTS phenotype associated with broad neurodevelopmental features, including an unusual speech difficulty (i.e., palilalia), and brain imaging studies revealed an array of cortical anomalies (e.g., frontal simplified gyration, focal frontal cortical dysplasia). These clinical and radiological observations expand the known WDSTS-related neurodevelopmental phenotypes and further strengthen the important role of KMT2A in brain function and cortical development.

Technical development in cardiac CT: current standards and future improvements-a narrative review

Non-invasive depiction of coronary arteries has been a great challenge for imaging specialists since the introduction of computed tomography (CT). Technological development together with improvements in spatial, temporal, and contrast resolution, progressively allowed implementation of the current clinical role of the CT assessment of coronary arteries. Several technological evolutions including hardware and software solutions of CT scanners have been developed to improve spatial and temporal resolution. The main challenges of cardiac computed tomography (CCT) are currently plaque characterization, functional assessment of stenosis and radiation dose reduction. In this review, we will discuss current standards and future improvements in CCT.

Malignancy course of pituitary adenoma in MEN1 syndrome: Clinical-Neuroradiological signs

Pituitary carcinomas (PCa) are extremely rare, indistinguishable from pituitary adenomas on histopathological grounds and have a poor prognosis. Most PCa start as PRL or ACTH secreting tumors in males, with relapsing invasive behaviour, refractoriness to medical and radiotherapy and increasing hormonal levels. The presence of distant metastases is still required for the diagnosis of PCa. The association with genetic endocrine diseases must be taken into account, since it adds further risk of evolution towards malignancy. Intradural spinal metastases have also been reported, so a complete craniospinal MR evaluation is recommended, when clinically indicated. We report a case of PCa, associated with MEN1 syndrome, with evidence of meningeal spread to the tentorium cerebelli, clival dura and spinal drop metastases mimicking spinal nerves schwannomas.

Increased functional connectivity in gambling disorder correlates with behavioural and emotional dysregulation: Evidence of a role for the cerebellum

Gambling disorder (GD) is a psychiatric disease that has been recently classified as a behavioural addiction. So far, a very few studies have investigated the alteration of functional connectivity in GD patients, thus the concrete interplay between relevant function-dependent circuitries in such disease has not been comprehensively assessed. The aim of this research was to investigate resting-state functional connectivity in GD patients, searching for a correlation with GD symptoms severity. GD patients were assessed for gambling behaviour, impulsivity, cognitive distortions, anxiety and depression, in comparison with healthy controls (HC). Afterwards, they were assessed for resting-state functional magnetic resonance imaging; functional connectivity was assessed through a data-driven approach, by using independent component analysis. The correlation between gambling severity and the strength of specific resting-state networks was also investigated. Our results show that GD patients displayed higher emotional and behavioural impairment than HC, together with an increased resting state functional connectivity in the network including anterior cingulate cortex, the caudate nucleus and nucleus accumbens, and within the cerebellum, in comparison with the control group. Moreover, a significant correlation between behavioural parameters and the strength of the resting-state cerebellar network was found. Overall, the functional alterations in brain connectivity involving the cerebellum observed in this study underpin the emotional and behavioural impairment recorded in GD patients. This evidence suggests the employment of novel neuromodulatory therapeutic approaches involving specific and salient targets such as the cerebellum in addictive disorders.

Oropharyngeal Hairy Polyp: A Case of Respiratory Failure in a Newborn

Hairy polyps, also known as dermoid polyps (DPs), are rare benign cystic lesions of bigerminal origin that may occur in several head and neck regions, including the oropharynx. Despite their benign histopathological nature, DPs may be life threatening, due to their upper airway location, and DPs represent one of the most unusual causes of respiratory distress during the neonatal period. In this paper, we describe a case of respiratory failure in a newborn with an oropharyngeal mass that was accidentally found during difficult intubation. Magnetic resonance imaging (MRI) detected a well-defined soft tissue pedunculated mass, arising from the left oropharynx wall, consistent with an oropharyngeal DP. The newborn had a prompt recovery after trans-oral mass removal. Our case underlines the importance of imaging in differential diagnosis of children’s respiratory distress, secondary to a variety of lesions within the region of the skull base or oropharynx. It allowed us to assess the origin of the lesion, as well as its relationship with the adjacent soft tissues, and to exclude intracranial extension, thus providing essential information for the surgical planning.

Neurochemical Correlates of Brain Atrophy in Fibromyalgia Syndrome: A Magnetic Resonance Spectroscopy and Cortical Thickness Study

(1) Background: Recently, a series of clinical neuroimaging studies on fibromyalgia (FM) have shown a reduction in cortical volume and abnormally high glutamate (Glu) and glutamate + glutamine (Glx) levels in regions associated with pain modulation. However, it remains unclear whether the volumetric decreases and increased Glu levels in FM are related each other. We hypothesized that higher Glu levels are related to decreases in cortical thickness (CT) and volume in FM patients. (2) Methods: Twelve females with FM and 12 matched healthy controls participated in a session of combined 3.0 Tesla structural magnetic resonance imaging (MRI) and single-voxel MR spectroscopy focused on the thalami and ventrolateral prefrontal cortices (VLPFC). The thickness of the cortical and subcortical gray matter structures and the Glu/Cr and Glx/Cr ratios were estimated. Statistics included an independent t-test and Spearman’s test. (3) Results: The Glu/Cr ratio of the left VLPFC was negatively related to the CT of the left inferior frontal gyrus (pars opercularis (p = 0.01; r = −0.75) and triangularis (p = 0.01; r = −0.70)). Moreover, the Glx/Cr ratio of the left VLPFC was negatively related to the CT of the left middle anterior cingulate gyrus (p = 0.003; r = −0.81). Significantly lower CTs in FM were detected in subparts of the cingulate gyrus on both sides and in the right inferior occipital gyrus (p < 0.001). (4) Conclusions: Our findings are in line with previous observations that high glutamate levels can be related, in a concentration-dependent manner, to the morphological atrophy described in FM patients.

Intraoperative imaging findings in transcranial MR imaging-guided focused ultrasound treatment at 1.5T may accurately detect typical lesional findings correlated with sonication parameters

OBJECTIVES

To assess the intraoperative neuroimaging findings in patients treated with transcranial MR-guided focused ultrasound (tcMRgFUS) thalamotomy using 1.5T equipment in comparison with the 48-h follow-up.

METHODS

Fifty prospectively enrolled patients undergoing unilateral tcMRgFUS thalamotomy for either medication-refractory essential tremor (n = 39) or Parkinson tremor (n = 11) were included. Two radiologists evaluated the presence and size of concentric lesional zones (zone I, zone II, and zone III) on 2D T2-weighted sequences acquired intraoperatively after the last high-energy sonication and at 48 h. Sonication parameters including number of sonications, delivered energy, and treatment temperatures were also recorded. Differences in lesion pattern and size were assessed using the McNemar test and paired t test, respectively.

RESULTS

Zones I, II, and III were visualized in 34 (68%), 50 (100%), and 44 (88%) patients, and 31 (62%), 50 (100%), and 45 (90%) patients after the last high-energy sonication for R1 and R2, respectively. All three concentric zones were visualized intraoperatively in 56-58% of cases. Zone I was significantly more commonly visualized at 48 h (p < 0.001). Diameter of zones I and II and the thickness of zone III significantly increased at 48 h (p < 0.001). Diameters of zones I and II measured intraoperatively demonstrated significant correlation with thermal map temperatures (p ≤ 0.001). Maximum temperature significantly correlated with zone III thickness at 48 h. A threshold of 60.5° had a sensitivity of 56.5-66.7% and a specificity of 70.5-75.5% for thickness > 6 mm at 48 h.

CONCLUSIONS

Intraoperative imaging may accurately detect typical lesional findings, before completing the treatment. These imaging characteristics significantly correlate with sonication parameters and 48-h follow-up.

KEY POINTS

• Intraoperative T2-weighted images allow the visualization of the zone I (coagulation necrosis) in most of the treated patients, while zone II (cytotoxic edema) is always detected. • Lesion size depicted with intraoperative transcranial MRgFUS imaging correlates well with procedure parameters. • Intraoperative transcranial MRgFUS imaging may have a significant added value for treating physicians.

S-Detect characterization of focal breast lesions according to the US BI RADS lexicon: a pictorial essay

High-resolution ultrasonography (US) is a valuable tool in breast imaging. Nevertheless, US is an operator-dependent technique: to overcome this issue, the American College of Radiology (ACR) has developed the breast imaging-reporting and data system (BI-RADS) US lexicon. Despite this effort, the variability in the assessment of focal breast lesions (FBLs) with the use of BI-RADS US lexicon is still an issue. Within this framework, evidence shows that computer-aided image analysis may be effective in improving the radiologist's assessment of FBLs. In particular, S-Detect is a newly developed image-analytic computer program that provides assistance in morphologic analysis of FBLs seen on US according to the BI-RADS US lexicon. This pictorial essay describes state-of-the-art of sonographic characterization of FBLs by using S-Detect.

CEUS LI-RADS: a pictorial review

Contrast-enhanced ultrasound (CEUS) greatly improved the diagnostic accuracy of US in the detection and characterization of focal liver lesions (FLLs), and it is suggested and often included in many international guidelines as an important diagnostic tool in the imaging work-up of cirrhotic patients at risk for developing hepatocellular carcinoma (HCC). In particular, CEUS Liver Imaging Reporting and Data System (LI-RADS) provides standardized terminology, interpretation, and reporting for the diagnosis of HCC. The aim of this pictorial essay is to illustrate CEUS features of nodules discovered at US in cirrhotic liver according to LI-RADS categorization.

Lacrimal gland herniation in Graves ophthalmopathy: a simple and useful MRI biomarker of disease activity

BACKGROUND

Lacrimal gland (LG) involvement in patients with Graves ophthalmopathy (GO) has been considered as a potential cause of the associated GO symptoms and different studies demonstrated the LG involvement in patients with GO than healthy controls. The aim of this study was to evaluate LG involvement, through measurement of its herniation, using a magnetic resonance imaging (MRI) index, in patients with different GO activities.

METHODS

Thirty-two consecutive Caucasian patients affected by GO were enrolled and grouped in group A (16 with inactive GO, CAS < 3) and B (16 with active GO, CAS ≥ 3) according to their GO activity. All patients underwent clinical-endocrinological assessment, a complete ocular evaluation, and orbital MRI examination.

RESULTS

No difference was found between the hormonal parameters, thyroid ultrasound-derived parameters, and thyroid-stimulating hormone (TSH) receptor (TSH-R) antibodies (TRAb) levels in group B and those in group A. The LG herniation (LGH) measurement evaluated by MRI was significantly higher in group B for both right (10.1 (7.3-17) vs. 7 (0-3.4) mm; p = 0.004) and left (8.5 (6.6-13) vs. 5.8 (0-12) mm; p = 0.026) eye than group A. A positive correlation was found between TRAb and LGH herniation (Rho 0.462, p = 0.009).

CONCLUSIONS

Measurement of LGH seems to be a good marker of the disease and GO activity.

KEY POINTS

• Lacrimal gland herniation is a simple index related to disease activity • Lacrimal gland herniation is correlated to TRAb levels • Lacrimal gland evaluation could be useful to differentiate active from inactive Graves ophthalmopathy in an early stage of disease.

Preliminary experience with a transcranial magnetic resonance-guided focused ultrasound surgery system integrated with a 1.5-T MRI unit in a series of patients with essential tremor and Parkinson's disease

OBJECTIVE Transcranial magnetic resonance-guided focused ultrasound surgery (tcMRgFUS) is one of the emerging noninvasive technologies for the treatment of neurological disorders such as essential tremor (ET), idiopathic asymmetrical tremor-dominant Parkinson's disease (PD), and neuropathic pain. In this clinical series the authors present the preliminary results achieved with the world's first tcMRgFUS system integrated with a 1.5-T MRI unit. METHODS The authors describe the results of tcMRgFUS in a sample of patients with ET and with PD who underwent the procedure during the period from January 2015 to September 2017. A monolateral ventralis intermedius nucleus (VIM) thalamic ablation was performed in both ET and PD patients. In all the tcMRgFUS treatments, a 1.5-T MRI scanner was used for both planning and monitoring the procedure. RESULTS During the study period, a total of 26 patients underwent tcMRgFUS thalamic ablation for different movement disorders. Among these patients, 18 were diagnosed with ET and 4 were affected by PD. All patients with PD were treated using tcMRgFUS thalamic ablation and all completed the procedure. Among the 18 patients with ET, 13 successfully underwent tcMRgFUS, 4 aborted the procedure during ultrasound delivery, and 1 did not undergo the tcMRgFUS procedure after stereotactic frame placement. Two patients with ET were not included in the results because of the short follow-up duration at the time of this study. A monolateral VIM thalamic ablation in both ET and PD patients was performed. All the enrolled patients were evaluated before the treatment and 2 days after, with a clinical control of the treatment effectiveness using the graphic items of the Fahn-Tolosa-Marin tremor rating scale. A global reevaluation was performed 3 months (17/22 patients) and 6 months (11/22 patients) after the treatment; the reevaluation consisted of clinical questionnaires, neurological tests, and video recordings of the tests. All the ET and PD treated patients who completed the procedure showed an immediate amelioration of tremor severity, with no intra- or posttreatment severe permanent side effects. CONCLUSIONS Although this study reports on a small number of patients with a short follow-up duration, the tcMRgFUS procedure using a 1.5-T MRI unit resulted in a safe and effective treatment option for motor symptoms in patients with ET and PD. To the best of the authors' knowledge, this is the first clinical series in which thalamotomy was performed using tcMRgFUS integrated with a 1.5-T magnet.

Renal endometriosis mimicking complicated cysts of kidney: report of two cases

Endometriosis is a common gynecologic disorder characterized by ectopic endometrial tissue growth outside the uterine cavity. Although usually occurring in pelvic organs, endometrial lesions may involve urinary tract. Renal endometriosis is extremely rare and it has only occasionally been reported in the past. We report two cases of patients with renal cystic lesions, incidentally found at imaging techniques during oncologic follow-up for gastric sarcoma and melanoma, initially misinterpreted as complicated haemorrhagic cysts and then histologically characterized as renal localizations of extragenital endometriosis.

Routinary use of fibrin sealants to prevent prolonged air leak in thoracic surgery: our experience

INTRODUCTION

Prolonged air leak (PAL) is one of the most common postoperative complications after lung surgery. It is associated with increased significant morbidity, lower quality of life, longer hospital stay and higher hospital costs. Since its great clinical and economic burden, it is important to establish the feasibility and the effectiveness of the routinary preventive use of a fibrin sealant in order to reduce the incidence of prolonged air leaks.

PATIENTS AND METHODS

This is a randomized study on 189 adult patients - 118 men (62.4%) and 71 women (37.6%) aged from 39 to 87 y.o. (mean age 68.3 y.o.) - who underwent lung surgery (lobectomy or bilobectomy) with intraoperatory detection of air leakage, from January 2013 to December 2017, at Department of Thoracic Surgery in "Ospedale Maggiore Carlo Alberto Pizzardi" (Bologna, Italy) and Department of Thoracic Surgery in "Paolo Giaccone" Teaching Hospital (Palermo, Italy). Patients were randomly assigned to the "Glue" arm (90 patients) or the "Control" group (99 patients). We only used stapler or manual suture to achieve aerostasis. In addition, we used a fibrin sealant ("glue") to cover the suture line on patients in the "Glue" arm. The primary endpoints were incidence of prolonged air leaks, days with chest tube and mean hospital stay.

RESULTS

In the "Glue" arm we experienced only 1 prolonged air leak (1.1%), while in the "Control" group there were 8 leaks (8.1%). Patients kept chest tube for average 4.15 days in the "Glue" arm and 4.45 days in the "Control" group. The mean hospital stay was average 7.4 days for the "Glue" arm, while 9.1 days in the "Control" group.

CONCLUSIONS

According to our experience it seems that the routinary preventive use of a fibrin sealant results in a lower incidence of prolonged air leaks, a shorter hospital stay with lower hospital costs, representing a cost-effective, feasible and effective system to decrease morbility and mortality among surgical patients.

Transcranial magnetic resonance-guided focused ultrasound surgery at 1.5T: a technical note

Magnetic resonance-guided focused ultrasound is one of the emerging non-invasive technologies offering both image guidance and thermal monitoring. In recent years transcranial application of this technology is starting to impact heavily the neuroscience field. We present here the imaging protocol and the technological methods successfully used with a transcranial magnetic resonance-guided focused ultrasound system certified for clinical treatments of functional neurological disorders, integrated for the first time with a 1.5T magnetic resonance scanner. Compared to the body radiofrequency coil (the one commonly used with transcranial magnetic resonance-guided focused ultrasound system integrated with 3T magnetic resonance scanners), the use of a dedicated two channel coil enabled a signal-to-noise ratio gain up to five times higher.

HIFU for Bone Metastases and other Musculoskeletal Applications

High-intensity focused ultrasound (HIFU) is a totally noninvasive procedure that has shown promising results in the management of numerous malignant and nonmalignant conditions. Under magnetic resonance or ultrasound guidance, high-intensity ultrasound waves are focused on a small, well-defined target region, inducing biologic tissue heating and coagulative necrosis, thus resulting in a precise and localized ablation. This treatment has shown both great safety and efficacy profiles, and may offer a multimodal approach to different diseases, providing pain palliation, potential local tumor control, and, in some cases, remineralization of trabecular bone. In musculoskeletal field, HIFU received FDA approval for treating bone metastasis, but its application has also been extended to other conditions, such as osteoid osteoma, desmoid tumor, low-flow vascular malformation, and facet joint osteoarthritis. This article illustrates the basic principles of HIFU and its main effects on biologic tissues with particular attention on bone, provides a step-by-step description of the HIFU procedure, and discusses the commonly treated conditions, in particular bone metastases.

Crohn’s disease and extra intestinal granulomatous lesions

Crohn’s disease (CD) is an inflammatory bowel disease with a multifactorial etiology. Clinical features include mucosal erosion, diarrhea, weight loss and other complications such as formation of granuloma. In CD, granuloma is a non-neoplastic epithelioid lesion, formed by a compact aggregate of histiocytes with the absence of a central necrosis, however, the correlation among CD and the formation of granulomas is unknown. Many cases of granulomas in the extracellular site, related to CD, have been reported in the literature. These granulomas, at times, represented the only visible manifestation of the pathology. Extra intestinal granulomas have been found on ovaries, lungs, male genitalia, female genitalia, orofacial regions and skin. From the data in the literature it could be hypothesized that there is a cross-reaction of the immune system with similar antigenic epitopes belonging to different sites. This hypothesis, if checked, can place CD not only among inflammatory bowel disease but also among inflammatory diseases with systemic involvement.

Preoperative evaluation of peripheral nerve injuries: What is the place for ultrasound?

OBJECTIVE

The purpose of this study was to evaluate the usefulness of ultrasound in the preoperative workup of peripheral nerve lesions and illustrate how nerve ultrasonography can be integrated in routine clinical and neurophysiological evaluation and in the management of focal peripheral nerve injuries. The diagnostic role and therapeutic implications of ultrasonography for different neuropathies are described.

METHODS

The authors analyzed the use of ultrasound in 119 entrapment, tumoral, posttraumatic, or postsurgical nerve injuries of limbs evaluated in 108 patients during 2013 and 2014. All patients were candidates for surgery, and in all cases the evaluation included clinical examination, electrodiagnostic studies (nerve conduction study and electromyography), and ultrasound nerve study.

Ultrasound was used to explore the nerve fascicular echotexture, continuity, and surrounding tissues. The maximum cross-sectional area (CSA) and the presence of epineurial hyperechogenicity or intraneural hyper- or hypoechogenicity, of anatomical anomalies, dynamic nerve dislocations, or compressions were recorded.

The concordance rate of neurophysiological and ultrasonographic data was analyzed, classifying ultrasound findings as confirming, contributive, or nonconfirming with respect to electrodiagnostic data. The correlation between maximum nerve CSA and neurophysiological severity degree in entrapment syndromes was statistically analyzed.

RESULTS

Ultrasonography confirmed electrodiagnostic findings in 36.1% of cases and showed a contributive role in the diagnosis and surgical planning in 53.8% of all cases; the findings were negative (“nonconfirming”) in only 10.1% of the patients. In 16% of cases, ultrasound was not only contributive, but had a key diagnostic role in the presence of doubtful electrodiagnostic findings. The contributive role differed according to etiology, being higher for tumors (100%) and for posttraumatic or postsurgical neuropathies (72.2%) than for entrapment neuropathies (43.8%).

CONCLUSIONS

Ultrasound is a powerful, noninvasive tool for the examination of peripheral nerve injuries, and can guide diagnosis of and surgical strategy for focal peripheral nerve injuries. It allows direct visualization of the cause and extent of nerve lesions and finds its place between electrodiagnostic tests and exploratory surgery. It can provide invaluable information, such as the presence and extent of a mass, scar compression, or neuromas. The authors recommend it as a complement to routine clinical and neurophysiological evaluation and as the first-line imaging modality for masses of suspected nerve origin.

[Non-invasive trans-cranial magnetic resonance imaging-guided focused ultrasounds surgery to treat neurologic disorders]

In past years non-invasive clinical applications of magnetic resonance-guided focused ultrasound for the treatment of neurological disorders have been hampered by technical limitations that today have been finally overcome. In 2015, for the first time in the world, the very first treatments have been performed in Italy by the use of an affordable 1.5T magnetic resonance unit. The clinical results obtained to date and all the future possible applications are very promising and pave the way towards safe and effective treatment options once unthinkable.

The Presence of White Matter Lesions Is Associated With the Fibrosis Severity of Nonalcoholic Fatty Liver Disease

We tested whether nonalcoholic fatty liver disease (NAFLD) and/or its histological severity are associated with vascular white matter lesions (WML) in patients with biopsy-proven NAFLD and in non-NAFLD controls. Data were recorded in 79 consecutive biopsy-proven NAFLD, and in 82 controls with normal ALT and no history of chronic liver diseases, without ultrasonographic evidence of steatosis and liver stiffness value <6 KPa. All subjects underwent magnetic resonance assessment and WML were classified according to the Fazekas score as absent (0/III), or present (mild I/III; moderate II/III, and severe I/III). For the purpose of analyses, all controls were considered without NASH and without F2-F4 liver fibrosis. WML were found in 26.7% of the entire cohort (43/161), of moderate-severe grade in only 6 cases. The prevalence was similar in NAFLD versus no-NAFLD (29.1% vs 24.3%; P = 0.49), but higher in NASH vs no-NASH (37.7% vs 21.2%, P = 0.02) and F2-F4 vs F0-F1 fibrosis (47.3% vs 20.3%, P = 0.001). In both the entire cohort and in NAFLD, only female gender (OR 4.37, 95% CI: 1.79-10.6, P = 0.001; and OR 5.21, 95% CI: 1.39-19.6, P = 0.01), age > 45 years (OR 3.09, 95% CI: 1.06-9.06, P = 0.03; and OR 11.1, 95% CI: 1.14-108.7, P = 0.03), and F2-F4 fibrosis (OR 3.36, 95% CI: 1.29-8.73, P = 0.01; and OR 5.34, 95% CI: 1.40-20.3, P = 0.01) were independently associated with WML (mostly of mild grade) by multivariate analysis. Among NAFLD, the prevalence of WML progressively increased from patients without (1/18; 5.5%), or with 1 (1/17, 5.8%), to those with 2 (9/30; 30%) and further to those with 3 (12/14; 85.7%) risk factors. The presence of WML is not associated with NAFLD, but with metabolic diseases in general, and fibrosis severity of NAFLD. Clinical implications of this issue need to be assessed by longitudinal studies.