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Highlights•We assessed the role of imaging in encephalitis.•We assessed the agreement between raters on scan interpretation.•Diagnosis for herpes simplex encephalitis (HSE) was good.•Agreement was worse for ADEM and other alternative aetiologies.•HSE can be dismissed if MRI normal 72 hours after neurological symptom onset (with negative CSF tests).AbstractAimTo assess the role of imaging in the early management of encephalitis and the agreement on findings in a well-defined cohort of suspected encephalitis cases enrolled in the Prospective Aetiological Study of Encephalitis conducted by the Health Protection Agency (now incorporated into Public Health England).Materials and methodsEighty-five CT examinations from 68 patients and 101 MRI examinations from 80 patients with suspected encephalitis were independently rated by three neuroradiologists blinded to patient and clinical details. The level of agreement on the interpretation of images was measured using the kappa statistic. The sensitivity, specificity, and negative and positive predictive values of CT and MRI for herpes simplex virus (HSV) encephalitis and acute disseminated encephalomyelitis (ADEM) were estimated.ResultsThe kappa value for interobserver agreement on rating the scans as normal or abnormal was good (0.65) for CT and moderate (0.59) for MRI. Agreement for HSV encephalitis was very good for CT (0.87) and MRI (0.82), but only fair for ADEM (0.32 CT; 0.31 MRI). Similarly, the overall sensitivity of imaging for HSV encephalitis was ∼80% for both CT and MRI, whereas for ADEM it was 0% for CT and 20% for MRI. MRI specificity for HSV encephalitis between 3–10 days after symptom onset was 100%.ConclusionThere is a subjective component to scan interpretation that can have important implications for the clinical management of encephalitis cases. Neuroradiologists were good at diagnosing HSV encephalitis; however, agreement was worse for ADEM and other alternative aetiologies. Findings highlight the importance of a comprehensive and multidisciplinary approach to diagnosing the cause of encephalitis that takes into account individual clinical, microbiological, and radiological features of each patient.
A 41-year-old female patient was admitted with streptococcal meningitis on a background of 5-month history of CSF rhinorrhoea. Imaging revealed an extensive skull base lesion involving the sphenoid and ethmoid sinuses, the pituitary fossa with suprasellar extension and bony destruction. Histological examination of an endonasal transethmoidal biopsy suggested a diagnosis of olfactory neuroblastoma. A profuse CSF leak occurred and the patient developed coliform meningitis. A second endonasal endoscopic biopsy was undertaken which demonstrated the tumour to be a prolactinoma. Following endonasal repair of the CSF leak and lumbar drainage, she developed profound pneumocephalus. The patient underwent three further unsuccessful CSF leak repairs. Definitive control of the CSF leak was finally achieved through a transcranial approach with prolonged lumbar drainage. This case illustrates some of the potentially devastating complications which can occur as a consequence of complex skull base lesions. A multidisciplinary approach may be required to successfully manage such cases.
A significant minority of aneurysms treated by endovascular means undergo additional subsequent therapy to treat aneurysm recurrence. Our study was undertaken to determine the risk of additional coil embolization of aneurysms recurring following endovascular therapy.Patients were identified during a 10-year period from prospectively collated data bases at 2 different neuroscience institutions. Patient outcome was obtained from the data bases or the patient's neurosurgical records. Occlusion grade was assessed at the time of treatment and at follow-up angiography as complete, near-complete, or incomplete.Of a total of 1834 aneurysms in 1631 patients, 100 aneurysms in 99 patients treated between January 1996 and December 2005 required additional coiling because of an enlarging remnant and subtotal occlusion. This comprised 6% of the patients treated and 8% of the total followed. Thromboembolic events complicated 3 retreatment procedures, but all 3 patients remain independent. Ninety-five patients were followed for 8-103 months (mean, 42.3 months) by conventional or MR angiography.Coil embolization of aneurysm recurrences has a low complication rate and leads to satisfactory occlusion in most cases. The risk from additional coil embolization does not negate the advantage of the initial embolization.
Objectives. The purpose of this study was to investigate the natural history of the high signal intensities shown on long TR sequences—neurofibromatosis type 1 bright objects (NBO)—in children with neurofibromatosis type 1 (NF1). We have paid particular attention to the development of tumors in these areas of abnormality. Methods. During a 12-month period in 1992 to 1993, 46 children with clinically proven NF1 had a magnetic resonance (MR) examination at our institution. These were reviewed along with any previous or subsequent MR examinations that had been performed. We recorded the number, volume, and distribution of the abnormal high signal intensities and their change with time when serial examinations were performed. Results. NBO were found in 93% of 46 children with NF1 on the original cross-sectional study. The most common anatomic sites were the globus pallidus (30.4%), cerebellum (23.5%), and midbrain (16.2%). The number and volume of NBO varied significantly with age. NBO were uncommon in children younger than 4 years but were very common and extensive between 4 to 10 years. A significant reduction in the number and volume of NBO was demonstrated in children older than 10 years as shown on both the cross-sectional and longitudinal portions of the study. Eight brain tumors (nonoptic pathway) were demonstrated in the 46 children (17%) with 1 child having two tumors. Only 1 child had symptoms referable to the tumor at the time of diagnosis. Five tumors developed in NBO that were documented on serial MR examinations. All those cases developed in children aged 7 to 12 years, and all these children had higher than average numbers and volumes of NBO. Conclusions. NBO occur commonly in children with NF1 and are most prevalent between the ages of 4 and 10. We have shown a high frequency of brain tumors in our children with NF1, but the majority of these were asymptomatic. We have demonstrated proliferative change NBO in 11% of 46 children. Most NBO regress with age and seem to be benign, however, young children with a large number and volume of NBO should be followed closely with regular MR examinations because of an increased risk of proliferative change. neurofibromatosis type 1, magnetic resonance, tumor, astrocytoma, childhood.
Poster: ECR 2014 / C-1972 / A Pictorial Review of Conus Medullaris Lesions With Differential Diagnosis by: E. Rees, A. Sahu, W.-X. Chong, D. Khan, S. Hamilton, W. M. Adams, W. MUKONOWESHURO; Plymouth/UK
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